17 days old

Manager Utilization Management Compliance-SWHR CIN

Southwestern Health Resources CIN
Dallas, TX 75201
  • Job Code

Please note: Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is an affiliated company of Texas Health and UT Southwestern. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health or UT Southwestern employee.

Southwestern Health Resources Clinically Integrated Network (SWHR CIN) seeks to hire a Manager Utilization Management Compliance. The Manager of Compliance assists with the management and implementation of programs, policies, and practices to ensure that all departments complying with health plan(s), CMS, NCQA, URAC, HIPAA, and accreditation standards. The Manager of Compliance maintains strong understanding of current federal, state, and local regulatory requirements. This manager will actively participate in all internal and external audit activities.

Salary range is Min. $85,737/year to Max. $128,814/year - based on relevant experience

Location: Fort Worth, TX

Work Schedule

Full time, day shift

Job Description

Conducts periodic internal reviews or audits to ensure that compliance procedures are followed.
Assists the Leadership in the implementation of compliance programs, policies, and procedures designed to ensure compliance with all applicable federal laws, Medicare Advantage (MA) regulations, and delegations requirements.
Conducts internal investigations of compliance issues.
Assists with the development of corrective action plans for issues identified during health plan audits.
Files appropriate compliance requirements with regulatory agencies (i.e. Texas Department of Insurance) as directed.
Participates in workflow design to ensure there is adequate oversight and monitoring in all required areas.
Maintains documentation of compliance activities, such as logs, complaints received, audits, and audit outcomes.
Discusses identified or emerging compliance issues with management or employees, as appropriate.
Assists internal management with the implementation or operation of compliance programs.
Comply with all compliance, regulatory and process training within the specified timeline
Aids internal or external auditors during compliance reviews.
Oversees Compliance Specialists activities.
Implements improvements in communication, monitoring, and enforcement of compliance standards, as directed by Director.
Verifies that all company and regulatory policies and procedures have been documented, implemented, and communicated.
Coordinates with delegated partners to ensure adherence to all regulations, contractual agreements, CMS, NCQA, and Department of Insurance guidelines.
Participates in delegation audits and provides information as needed.
Analyzes delegation audits and makes recommendations for improvement.
Performs tasks related to external audits from contracted health plans as well as pre-delegation reviews with potential health plans, as required.
Follows up on corrective action plans to ensure timely closure.
Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies.
Prepares adverse determination notices in compliance with regulatory requirements.
Completes documentation in applicable software system accurately and in accordance with: (a) eligibility and benefits, (b) clinical guidelines/criteria, (c) legal and regulatory requirements.
Understands and ensures compliance with the utilization management decision hierarchy for the medical review process as delegated by the health plans.
Utilizes resources efficiently and effectively. .

The ideal candidate will possess the following qualifications

Bachelor's Degree Nursing required
Master's Degree Nursing preferred

2 years experience in Medicare Advantage or Managed Care Compliance and 1 year leadership experience and 3 years clinical case management experience in an acute or post-acute provider setting (Utilization Review, Discharge Planning, and Medical Case Management preferred) is required

Licenses and Certifications
RN - Registered Nurse required upon hire
CCM - Certified Case Manager Certified in Case Management URAC recognized Case Management certification preferred upon hire

Working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc.
Possess strong analytical and organizational skills
Working knowledge and ability to apply professional standards of practice in work environment
Knowledge of specific regulatory, Texas Department of Insurance statutes, NCQA, URAC, CMS, and managed care requirements

Posted: 2019-10-31 Expires: 2019-11-29
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Manager Utilization Management Compliance-SWHR CIN

Southwestern Health Resources CIN
Dallas, TX 75201

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