11 days old

Medical Management Compliance Consultant

Capital BlueCross
Harrisburg, PA 17101
  • Job Code
    R2455

POSITION SUMMARY

The position is responsible for planning and executing UM and CM audits to evaluate compliance with federal and state regulations, Capital operational standards, and accreditation requirements; including audit of the case review focusing on clinical activities that includes case flow, system documentation, case collaboration both internally and externally. Internal audits will include a minimum of ten (10) cases per nurse per month. Audits of delegated clinical services will be conducted at a minimal on an annual basis.

Responsible for ensuring internal and delegated utilization management services performed by vendors. meets Capitals accreditation, contractual,federal and state regulations standards. Vendor oversight according to service level agreements within contracts and internal clinical activities are monitored for compliance for accreditation and regulatory requirements as the position supports all audit internal and external audit activities.

ESSENTIAL DUTIES & RESPONSIBILITIES

  • Responsible for planning and executing UM and CM audits
  • Responsible for presenting an audit findings report to management on a monthly basis, including the development and monitoring of correction action plans and follow-up activities.
  • Responsible for educating staff on findings, updating workflows and audit tool to ensure a consistent approach to documentation and case collaboration occurs.
  • Quarterly, annually and upon request, prepares written evaluation of clinical activities and UM programs to insure regulatory/accreditation/contract compliance, including presentation of the evaluations and audit activities to the appropriate committees and senior management for approval. Establishes appropriate benchmarks, and analyzes reports to determine if utilization and quality performance are appropriate. Identify opportunities for improving processes and outcomes.
  • Maintains appropriate documentation of records, reports, correspondence, of oversight activities to insure documentation meets both regulatory and accreditation standards, including for delegation when appropriate.
  • Participates in Capital Compliance programs. Monitors regulatory and accreditation standards for updates, and proposes updates to UM Policy and Procedures as required. Annually updates audit tool according to appropriate accreditation and regulatory standards.
  • Reports and documents potential quality issues, complaints, potential grievances, provider issues to Capitals Quality Improvement team for resolution. Assists the Quality Improvement team as necessary to provide research background information.
  • Performs other duties as assigned.
  • Responsible for planning and executing UM and CM audits
  • Responsible for presenting an audit findings report to management on a monthly basis, including the development and monitoring of correction action plans and follow-up activities.
  • Responsible for educating staff on findings, updating workflows and audit tool to ensure a consistent approach to documentation and case collaboration occurs.
  • Quarterly, annually and upon request, prepares written evaluation of clinical activities and UM programs to insure regulatory/accreditation/contract compliance, including presentation of the evaluations and audit activities to the appropriate committees and senior management for approval. Establishes appropriate benchmarks, and analyzes reports to determine if utilization and quality performance are appropriate. Identify opportunities for improving processes and outcomes.
  • Maintains appropriate documentation of records, reports, correspondence, of oversight activities to insure documentation meets both regulatory and accreditation standards, including for delegation when appropriate.
  • Participates in Capital Compliance programs. Monitors regulatory and accreditation standards for updates, and proposes updates to UM Policy and Procedures as required. Annually updates audit tool according to appropriate accreditation and regulatory standards.
  • Reports and documents potential quality issues, complaints, potential grievances, provider issues to Capitals Quality Improvement team for resolution. Assists the Quality Improvement team as necessary to provide research background information.
  • Performs other duties as assigned.

JOB REQUIREMENTS

Experience:

  • Two (2) years of experience in Quality Improvement preferred; five (5) years recent clinical experience.

Education and Certifications:

  • Registered Nurse with an active Pennsylvania license

Skills:

  • Strong communication and presentation skills.
  • Demonstrated organizational skills and ability to manage multiple tasks simultaneously.
  • The ability to prioritize job demands in an efficient manner.

Knowledge:

  • Knowledge of the Plans medical policies and standard review criteria.
  • Knowledge of ICD-10, DSM-IV, and CPT coding.
  • Knowledge of federal, state, Medicare, and accreditation requirements for delegation oversight and clinical programs.
  • Knowledge of accreditation and regulatory standards such as PA Department of Health NCQA, JCAHO, CMS.
  • Knowledge of the health care market including an understanding of the philosophy of managed care programs and principles, including utilization management and care management.

Work Environment:

  • Ability to work remotely/virtual

Physical Demands:

  • While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
  • The employee must be able to work over 40 hours per week.
  • The employee must occasionally lift and/or move up to 5 pounds.

    Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.







    Posted: 2021-06-09 Expires: 2021-07-08
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    Medical Management Compliance Consultant

    Capital BlueCross
    Harrisburg, PA 17101

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