Position Purpose:Performs highly advanced (senior-level) quality assurance and supervisory work. Oversees, manages, and monitors the quality assurance program and auditing process to ensure timeliness, accuracy, and consistency in reconsideration decisions. Works independently supervision, with considerable latitude for the use of initiative and independent judgement.
Essential Responsibilities:
- Oversees, manages, and plans quality audits to ensure decision makers adjudicate cases timely and accurately.
- Oversees and manages the Quality Program and planning the workflow among internal staff and subcontractors.
- Oversees, manages, plans and continually improves processes and identifies trends and changes to improve efficiency and control unit cost.
- Oversees, manages, plans, and forecasts workloads and resources to ensure accurate and timely processing of appeals.
- Oversees, plans, prepares, and reviews statistical and data analysis to identify problems, trends and improvement opportunities.
- Oversees, plans, and provides support during International Organization for Standardization (ISO) audits.
- Oversees, plans, and trains on the decision making protocols and guidelines, system assigning and reports, and guidelines, policy, and coverage errors found in quality audits to prevent future errors.
- Oversees, plans, and update work instructions as needed.
- Oversees, plans, and researches complex or new issues identified and provides guidance for first level reviewers, writes Decision Consistency Memos (DCMs)/Quality Tips, and develops educational/training material.
- Oversees, assigns, manages, and plans staff activities and workloads to ensure timeframes and deliverables are met.
- Oversees, manages, plans and implements an inter rater reliability (IRR) audit process that will validate consistency among decision makers or identify areas of improvement.
- Stays abreast of changes in policy, guidelines, and protocols to ensure needed changes are implemented timely.
- Assists in developing methodologies, protocols or templates to allow the decision making process to be more efficient.
- Assists in managing workflow and production of ALJ party and non-party hearings and position papers.
- Assists in providing timely and accurate responses to Federal and Congressional inquiries.
- Participates in special projects and performs other duties as assigned.
Minimum Qualifications
Education
- Associate's degree or 60 or more credit hours towards a Bachelor's degree from an accredited college or university in healthcare or related discipline
Experience
- Five (5) years clinical
- Five (5) years Medicare appeals decision making
- Five (5) years experience directly relevant to the specific task order or project
- Three (3) years management or supervisory
- Healthcare Professional with Three (3) years demonstrated experience writing or making medical necessity decisions
- Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience
- Demonstrated experience managing complex workloads in a Medicare or healthcare environment (i.e appeals, enrollment, inquiries)
- Qualified Independent Contractor, preferred
