Incumbent is responsible for the design, development and operational leadership of the Clinical Business Monitoring Team. Partner with Clinical Leadership to enhance and implement use of monitoring tools, specific defect and exception reports, implement process improvements, and develop training plans for clinical and non-clinical staff aimed at improving operational execution and compliance to state, federal and accrediting regulations and requirements. Develops and employs process monitoring tools to identify root cause of potential process deficiencies, and provides timely reporting on productivity, audit results and process improvement opportunities. Responsible for operational knowledge and subject matter expert for regulatory specifications for the business – Medicare and/or Medicaid – that govern both Utilization Management and Case Management functions as it relates to those regulations. Lead the business/operational translation specifications to the IT team for universe creation. Participate in Universe governance that would impact changes to the specification and ultimately impact compliance.
Reports to:Sr, Dir. Clinical Ops Oversight
Additional Responsibilities:Candidate Education:
- Manages and develops direct reports who include supervisory and/or exempt professional personnel including but not limited to hiring, mid-year and annual reviews, Performance Improvement Plans (PIP), terminations, etc.
- Ensures department activities are compliant with the regulations and standards that govern the industry.
- Coordinates with Regulatory Affairs in each line of business to ensure that corporate policy and addendums are compliant.
- Develops and implements departmental workflows and policies & procedures.
- Collaborates with other departments cross functionally regarding case management and/or Clinical Services initiatives.
- Partners with Management team to develop audit plans that identifies and prioritizes areas of significant risk.
- Reviews and audits the effectiveness of corrective action plans that address report findings and provides comprehensive follow-up to senior management at least monthly.
- Develops, implements and manages process improvement initiatives.
- Manages audit planning, including review of audit programs for multiple performance reviews specific to role or department.
- Applies a comprehensive knowledge of Care Model for telephonic and field care management programs.
- Proactively monitors appropriate metrics to improve both quality and drive efficiency.
- Partners with key stakeholders across clinical and non-clinical departments during external and internal audits in order to provide appropriate documentation and communication to ensure the audits are conducted in accordance with audit methodology, professional standards, NCQA, CMS, and state Medicaid requirements.
- Develops QA standards to monitor and improve adherence to department standards, policies and procedures, templates, formats and guidelines.
- Develops and implements studies of business function systems to include performance audit scores, action plans, and analysis. Prepares narratives and graphic display of the findings.
- Direct involvement in building collaborative relationships with other departments to resolve quality issues and barriers, i.e Provider Network, Quality, Advocacy, Utilization Management, etc.
- Performs special projects as needed.
- Required A Bachelor's Degree in Public Health, Nursing, Healthcare Administration, Business Management or related field
- Required or equivalent work experience 5 years in nursing, a clinical setting, managed care, or business reporting/analytics
- Required 5 years of experience in practical work in a business environment with data collection, creation and analytics
- Required 2 years experience in leading/supervising others
- Preferred 2 years of experience in An acute clinical care setting and/or managed care related experience
- Preferred 2 years of experience in Case management
- Preferred 2 years of experience in reading, analyzing, interpreting and/or applying State and Federal laws, rules and regulations
Licenses and Certifications:
- Advanced Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Advanced Demonstrated analytical skills
- Intermediate Other Detailed understanding of the Medicare and Medicaid rules and regulations
- Intermediate Ability to work independently Ability to work independently, handle multiple assignments and prioritize workload
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Ability to drive multiple projects
- Intermediate Demonstrated written communication skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to create, review and interpret treatment plans Ability to create, review and interpret treatment plans
- Intermediate Demonstrated negotiation skills
- Intermediate Ability to lead/manage others
- Advanced Knowledge of healthcare delivery
- Advanced Other Knowledge of NCQA, CMS, and state Medicaid requirements
- Advanced Ability to effectively present information and respond to questions from families, members, and providers
- Advanced Ability to effectively present information and respond to questions from peers and management
- Intermediate Ability to implement process improvements
- Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
A license in one of the following is required:
- Preferred Other One or more of the below
- Preferred Project Management Professional (PMP)
- Preferred Certified Business Analysis Professional (CBAP)
- Preferred Licensed Registered Nurse (RN)
- Preferred Licensed Certified Social Worker (LCSW)
- Preferred Licensed Marital and Family Therapist (LMFT)
- Preferred Licensed Mental Health Counselor (LMHC)
- Preferred Certified Case Manager (CCM)
- Required Advanced Microsoft Outlook Intermediate to high level efficiency in Microsoft Office including Outlook, Word and Excel
- Required Advanced Microsoft Word
- Required Advanced Microsoft Excel
- Required Advanced Other reporting analytic software (i.e. Tableau)
- Preferred Intermediate Microsoft Visio