Job Description
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
STATEMENT
This position is responsible for independently reviewing and analyzing clinical medical review decisions, identifying patterns of variability and opportunities for improvement as well as developing reference materials and training resources to support consistent and standardized application.
ESSENTIAL 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.
Quality Review: (50%)
* Develops a process for and conducts independent, accurate and timely inspection of clinical decisions to evaluate clinical review determinations.
* Analyzes the results of the quality checks, prepares reports of findings and works with the respective management if remedial training is needed. Conducts follow-up quality and inter-rater reviews as needed for identification of areas for improvement or on-going interventions.
* Leads, develops, and manages clinical quality improvement, including meeting planning and facilitation, recording of quality meeting minutes, assignment of follow-up tasks, and preparing reports and summaries. Collaborates with management, other departments and the Contractor Medical Directors (CMDs) to identify clinical areas of focus and indicators for regular monitoring or quarterly Inter-Rater Reliability.
Research & Analysis: (25%)
* Maintains detailed knowledge and understanding of federal and state regulatory review requirements as well as local and national policy to ensure clinical quality improvement initiatives are following standards and requirements.
* Provides clinical research and support to the CERT Team.
* Research and answer clinical review questions, as needed.
* Participates in provider education when requested.
Training & Development: (15%)
* On a monthly basis, provides input and/or participates in a strategic planning session to evaluate various data elements to identify new or continued areas of focus for clinical quality improvement initiatives in order to meet CMS requirements. Works with CMDs to interpret clinical practice guidelines based on review of the current scientific literature for areas of focus, as needed.
* Works collaboratively with management to ensure the guidelines are disseminated to team and/or providers.
* Provides feedback regarding performance and develops/initiates corrective actions for areas identified as needing improvement.
* Coordinates and produces quarterly Inter-Rater Reliability assessments.
Reporting & Outcomes: (10%)
* Prepares and distributes quality reports and intervention plans with management for input and feedback/direction.
* Reports monthly quality scores for inclusion in the QMR reports.
* Reports quarterly Inter-Rater Reliability scores.
* Recommends process improvements designed to improve accuracy, timeliness of processing and/or eliminate manual effort.
Performs other duties as the supervisor may, from time to time, deem necessary.
REQUIRED QUALIFICATIONS
* High School diploma or GED
* 3 years' related work experience with a minimum of 2 years' clinical experience
* Computer literacy
* Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)
* Knowledge of Medicare policy, guidelines, regulations, protocols, and local and national coverage determinations
* Strong analytical, problem solving and communication skills
CERTIFICATIONS, LICENSES, REGISTRATIONS
* Valid unrestricted Registered Nurse (RN) license
PREFERRED QUALIFICATIONS
* Bachelor of Science in Nursing (BSN)
* 5-7 years of clinical experience
* 5 years' experience in the insurance industry with that time in a clinical decision-making setting
* Experience developing and running process improvement initiatives, skilled in project planning and able to work within tight time frames, utilizing both internal and external resources
* Operational knowledge of relevant Medicare processes
* Ability to understand and evaluate numerical data, tables, charts or graphs; perform calculations, make comparisons and combine quantitative information
* Strong presentation skills
* Experience with committee facilitation
CERTIFICATIONS, LICENSES, REGISTRATIONS
* CPC (Certified Professional Coder)
Qualifications
The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company. These years of residence do not have to be consecutive.
Background Investigation: If you are selected for this position, you must undergo a pre-employment Background Investigation, Drug Screen, and Identity Proofing documentation must be cleared prior to hire. Most positions are subject to additional Identity Proofing, Fingerprinting and additional Background Investigation screening conducted by the Federal Government to be granted Enterprise User Administration (EUA) system logical access after you begin your employment. Your continued employment is contingent upon the outcome of the complete additional screening criteria required for the position which must find that you meet the applicable government customer's requirements (e.g., suitable for access to CMS information and information systems), as well as any additional investigation which may be required throughout your employment. If you are found not suitable, your employment may be subject to corrective action, up to and including immediate termination of employment.
Identity Documentation: You must have access to a current and unrestricted REAL ID, U.S. Passport, U.S. Passport Card, Foreign Passport, or U.S. Permanent Residency Documents. Note: Employment Authorization Cards (EAD) are not a substitute for Visas or U.S. Permanent Resident Cards.
"We are an Equal Opportunity/Protected Veteran/Disabled Employer."
This opportunity is open to remote work in the following approved states: AL, AR, FL, GA, ID, IN, IO, KS, KY, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require further approval. In FL and PA in-office and hybrid work may also be available.
