Accountable to provide guidance and clinical support to Utilization Management and Operations Compliance leadership and associates related to regulatory requirements and accreditation standards. Remains current with knowledge of URAC, NCQA, and CMS standards and with all federal and state regulations related to CareCentrix UM program and service delivery. Position will coordinate with Director of Operational Compliance to establish an internal audit program based on compliance requirements, to identify areas of risk, and coordinate remediation of opportunities for improvement. Works with UM leadership to develop reporting, training and business support tools to ensure ongoing compliance with all requirements – both clinical and operational. Through the ongoing collection and analysis of data, will identify and facilitate continuous improvement efforts to ensure compliance with accrediting, customer and legal requirements pertaining to utilization management and clinical review. Will support accreditation and customer delegation oversight audit processes by reviewing and developing policies to comply with standards and preparing for and participating in accreditation and customer utilization management delegation oversight audits. Responsible for tracking audit findings, developing issues and corrective action plans from remediation through to monitoring and oversight.
• Prepare for and participate in customer delegation oversight audits relating to utilization management, including preparation of audit tools and audit files.
• Serve as point of contact between operations and Corporate Compliance/Accreditation to receive updates on accreditation and regulatory requirements for UM and CareCentrix service delivery.
• Establish, administer and monitor an internal audit program focused on compliance elements that incorporates expectations of external audits for accreditation and regulatory purposes.
• Prepare for and participate in NCQA and URAC audits
• Perform internal utilization review audits and identify opportunities for improvement.
• Coordinate with Learning and Development to develop and deliver training to address improvement opportunities identified through audits
• Coordinate with Reliability, BI, BT, CMI, etc to execute on system updates required as identified through audits
• Monitor and communicate changes in accrediting standards and work with operational areas to implement changes required due to changes in accrediting standards
• Assist with policy and desk level procedure updates and training as identified through audits
• Work with UM Operations to promote accreditation and customer delegation oversight
ATTRIBUTES / QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis.
• Convey a strong professional image, exhibit interest and positive attitude toward all assigned work.
• Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
• Reviews and adheres to all company policies, procedures, and the Employee Handbook.
• Must be able to remain in a stationary position 90% of the time.
• Occasionally move about the office to access file cabinets, office machinery, etc.
• Constantly operates a computer and other office productivity machinery (i.e., a calculator, copy machine, and computer printer).
• Frequently communicates via phone and email. Must be able to exchange accurate information in these situations.
• Occasionally lift items weighing up to 10 pounds.
An experienced clinician with a minimum of three years of quality experience, preferably in the managed care setting is required. Bachelor’s Degree a must. Must have excellent interpersonal skills, ability to teach, thorough understanding of URAC, NCQA, CMS and state law standards pertaining to utilization management, project management skills, competent in the use of computers, statistical analysis, data display, auditing, skill with Microsoft Office. Clear and active Registered Nurse/LPN/LVN (based on allowable state practice act) license in any state(s) or jurisdiction in the United States is required. Experience in training, written communication, and reports desired.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.