Summary of Job: Partnering with the Medical Management Operations Senior Leadership in maintaining an effective quality and training program to ensure clinical and operational regulatory adherence with Federal, State and CMS regulations and NCQA accreditation requirements through monitoring and educational activities.
- Perform routine quality monitoring/audits, clinical and administrative, to measure adherence with state, federal, accreditation and business requirements associated with concurrent review utilization management requirements.
- Evaluate and develop a fluid monitoring work plan based on risk, newly deployed initiatives/regulations or changes in workflow/procedures.
- Performs mock audits, such as CMS, NCQA and State, on a routine basis with attention to the clinical documentation and validity of data.
- Provide ongoing reports of quality results, documenting issues and ensures appropriate corrective actions plans are deployed, including effectiveness therein. Provide coaching to staff on individual results, sharing feedback and expected improvements to direct leaders.
- Primary coordinator of the Medical Management Operations team for state, federal, accreditation and internal audits.
- Validation of universes associated with Federal, State and Accreditation utilizationaudits
- Preparation of Case Files
- Participant in all external regulatory and accreditation audits
- Development of effective corrective action plans with departmental leadership
- Assist departmental management in the development of concurrent review processes and procedures and lead efforts to create effective training modules to ensure regulatory and accreditation adherence.
- Develop, execute and maintain a clinical and administrative new hire orientation and training plan, annual training plan and coordinate ad hoc training for end to end concurrent review processes. Evaluate training for effectiveness.
- Ensure staff complete other trainings and required evaluations annually, including mandatory trainings and clinical evaluations such as interrater reliability studies.
- Maintains a working knowledge of relevant issues, laws, and regulations affecting Medical Management Operations.
- Assists in annual review of the regulatory adherence grid, incorporating applicable Federal, State and accreditation decision-making and notification timeliness requirements.
- Performs other tasks as assigned.
- Must have current, unencumbered NYS or Connecticut RN license
- 5 years’ experience in a managed healthcare environment required
- 3+ years of previous quality/audit and training experiencerequired
- Prior experience with CMS regulations and NCQA accreditation required
- Strong communication and presentation skills and the ability to interact with all levels of management and state, federal regulatory and accreditation agencies
- Excellent analytical, organizational, and problem solving skills
- Ability to multi-task many projects simultaneously