Title: Care Management Coordinator/RN
Location: 100% Remote
Duration: 3+ Months (FT conversion)
Job Description
Candidates will be remote but need to reside in the tri-state area.
UM RN - PA License. **No LPN candidates.
QUALITY LETTER REVIEW
Title: Compliance Specialist
Job Summary
The Compliance Specialist role assures that staff performance is compliant with the various regulations and standards applying to Utilization Management operations. These regulations include, NCQA, CMS and multiple state requirements. In addition, the Compliance Specialist monitors the medical review process to assure that staff are making appropriate medical necessity determinations, applying InterQual and medical policy correctly, and making accurate and well-documented referrals to Medical Directors, and documenting correctly for letter generation. This position is responsible for coordinating business operations support for NCQA activities (survey, annual document preparation and maintenance) as well the various projects and initiatives.
Responsibilities
• Assesses regulations and standards (NCQA, CMS and State) and assures appropriate controls are in place, making recommendations and overseeing implementation of new controls where necessary
• Reports potential issues and trends monthly impacting efficiency and quality based on compliance audit findings to Managers and Director
• Performs ongoing sample case reviews to assure that staff are applying InterQual and medical and departmental policy guidelines correctly and referring appropriate cases to the Medical Director. Assures that information provided to the Medical Director is relevant and helpful in making determinations
• Assures that clinical staff are documenting appropriately in medical management system so that member letters are clear, understandable, and meet regulatory requirements
• Acts as a resource for internal and external sources, utilizing excellent communication skills and responding in a timely and focused professional manner
• Other duties as assigned
Qualifications
• Minimum five (5) years clinical experience
• Active PA Licensed Registered Nurse required
• Registered nurse, BSN Preferred
• Must have strong interpersonal skills with demonstrated ability to provide associate feedback and support while maintaining positive, productive interpersonal relationships
• Knowledge of utilization review processes and utilization management systems, moderate to strong knowledge of InterQual required
• Excellent verbal and written communication skills with a key focus on attention to detail
• Strong use of Excel, Power Point and Word
• Experience adhering to NCQA, CMS and other programs requiring regulatory compliance
• Strong problem-solving abilities, organizational and planning skills
Benefits:
We offer a competitive compensation package that includes:
• [Pay Rate]: $42 - $46 per Hour
o Note: Pay rate will be commensurate with experience.
• Medical for full time employees
• Dental, and Vision Insurance
• Life Insurance, Short-Term Disability, Long-Term Disability, etc.