Job Description

In this position you will be leading a team of independent and autonomous Clinical Compliance Auditors and Specialists to ensure we follow the outlined Utilization Management (UM) and Population Health Management (PHM) Plan and Member Service Agreement (MSA) clinical requirements. With the assistance of the Clinical Compliance Manager, UM Manger, and PHM Manager you will create and develop annual goals to show clinical compliance is being met in real time by cross collaboration with the Leadership Team. You will strive for continuous improvement and an excellent work balance to produce top-notch results.

WHAT YOU'LL BE DOING

• Supervising and directing the day-to-day operations of the clinical compliance auditors and specialists.
• Serving as the clinical services liaison to senior management and other company leaders. Assisting in developing coordinated and efficient companywide team processes.
• Assisting with coordinating orientation, training, continuing education, and ongoing performance monitoring for clinical compliance auditors and other departments as required.
• Working with Leadership to promote the staff's continued professional growth and education.
• In conjunction with the Compliance Manager, UM Manager, and PHM Manager, overseeing and assisting with developing and managing the agenda and meeting minutes for the monthly utilization management data reported to the Independent Physician Association (IPA) UM Committee.
• Assisting with facilitating UM and PHM Plan development and adherence.
• Identifying UM and PHM Plan requirements and assisting in creating auditing guidelines to ensure clinical staff continue meeting the minimum requirements, including quarterly, semiannual, and annual submission requirements set forth in the UM and PHM Plan.
• Serving as a secondary reviewer to ensure adherence to the denial process and all denial compliance audit requirements. Reviewing and ensuring all documentation is submitted in a timely manner.
• Supporting the maintenance of confidentiality related to all computer programs, medical records, and other data.
• Applying critical thinking skills and decisive judgment while working with minimal supervision.
• Ensuring meeting minutes are completed, signed, and uploaded in accordance with UM and PHM Plan requirements.
• Assisting with all internal and external audit reviews and submissions.
• Completing monthly 30/30 reviews with the clinical compliance auditors and specialists.
• Maintaining a professional appearance during on-camera meetings.
• Performing other duties as assigned.

Qualifications

WHAT YOU'LL NEED FOR SUCCESS

• Registered Nurse with an active and unrestricted license in IL.
• Three to five years of experience in leading UM and PHM plan and MSA requirement changes.
• Experience in a managed care environment with multiple clients.
• Experience in the UM and PHM process and managed care.
• Strong organizational, written and presentation skills necessary.
• High analytical ability to define and describe complex problems.
• Ability to prioritize and react based on rapidly changing business needs.
• Proficient in the use of medical terminology and nationally recognized medical criteria.
• Computer skills including Microsoft Word, Excel, Outlook, PowerPoint etc.

WHAT WE'D LOVE YOU TO HAVE

• Claims processing experience
• Coding certificates are a plus

Additional Information

The salary range for this role will depend on the background and experience of the individual, ranging from $85,000.00 to $91,000.00 per year.

BENEFITS:

While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:

• Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
• Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
• Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
• Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
• Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
• Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
• Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.

All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. Temporary employees and contractors are not eligible for benefits.

COMPENSATION:

The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.

REMOTE WORK TECHNICAL REQUIREMENTS

Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection, capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 100 mbps download, 10 mbps upload. Please run a speed test here to confirm your internet connection meets these requirements.

SECONDARY EMPLOYMENT

At Guidehealth, we value transparency and collaboration as part of our commitment to excellence. As your primary employer, we kindly ask all team members to disclose any secondary employment, regardless of whether it may present a potential conflict of interest.

To ensure smooth teamwork and availability, employees must be accessible during our stated working hours. We foster connection and engagement by asking team members to join virtual meetings with their cameras on.

Videos To Watch
https://youtu.be/BAWs9H1UN2M