Are you interested in joining a team of experienced healthcare experts and have the ability to shape and transform the healthcare delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 million Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a better health experience for all consumers. Join our winning culture and help transform Medicare for the millions of people who rely on its services.
Benefits info:
• Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
• Short- and long-term disability benefits
• 401(k) plan with company match and immediate vesting
• Free telehealth benefits
• Free gym memberships
• Employee Incentive Plan
• Employee Assistance Program
• Rewards and Recognition Programs
• Paid Time Off and Paid Sick Leave
SUMMARY STATEMENT
This position is responsible for supervising and coordinating the varied and highly visible activities of operational departments that perform clinical reviews. This includes direct supervision of support staff and clinical professional staff in conducting medical review, provider education and appropriate referrals to the Unified Program Integrity Contractor (UPIC) for potential fraud and abuse related to the Medicare Program as well as various other external entities (e.g. Quality Improvement Organization (QIC), Recovery Auditor Contractor (RAC), Centers for Medicare and Medicaid Services (CMS), etc.).
ESSENTIAL DUTIES & RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.
1) Communicate effectively with all levels of the organization and outside entities by:
• Managing customer expectations (internal and external); facilitating, planning and designing training presentations, meetings, translating requirements for staff and peers, representing the company regarding clinical reviews with outside entities (e.g., Office of Inspector General (OIG), CMS, physician offices including compliance departments and corporate Chief Executive Officers (CEOs), etc.).
• Preparing and reviewing written procedures, policies, reports and correspondence; collaborating and training with other departments corporate wide.
• Preparing and reviewing written website materials to maximize communication with external customers.
• Collaborating with other departments and other stakeholders in identifying customer needs or concerns, considering available options, comparing costs and benefits, and recommending cost-effective recommendations.
2) Administering oversight activities:
• Providing direct oversight and/or technical direction as necessary of both technical support staff and clinical professional staff.
• Evaluating workflow of clinical workloads and adjusting when necessary. Supporting changes or improvements to base/non-base systems applications.
• Developing and implementation of performance expectations.
• Understanding and supporting operational policies and procedures.
• Actively identifying, developing and deploying process improvement activities.
• Identifying opportunities, through the use of Medicare policies and procedures, processing procedures and related data processing systems, to improve department's overall performance.
• Ensuring compliance with regulatory, legislative, CMS and company requirements and commitments.
• Analyzing internal processes for compliance to regulatory and enterprise requirements.
3) Accountable for the coordination and management of all technical support and clinical reviews and personnel and effective and efficient implementation of all clinical reviews including implementation and monitoring of the Improper Payment Reduction Strategy (IPRS), appeals, and/or prior authorization programs.
• Work with managers, Contractor Medical Directors, and other departments as well as own department manager to ensure appropriate clinical review activities are being conducted.
• Ensure appropriate clinical review resources are used efficiently and effectively in keeping within budget and CMS directives to conduct assigned activities, which could include educating (both written and verbal education) Medicare Part A and Part B physicians and suppliers on Medicare policies, coverage, and coding guidelines.
• Monitor the outcomes and effectiveness of clinical activities.
• Identify and recommend to management process improvements that will increase productivity and improve quality of outputs.
• Ensure compliance with corporate standards as well as applicable CMS requirements as they relate to change requests, management controls, process quality plans, the Medical Review (MR) quality program, int
Location: Mechanicsburg, PA
Posted: Aug. 13, 2024, 12:33 a.m.
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