Job Summary:Owns responsibility for ensuring the optimal performance of the medical review division, continuously monitoring and analyzing performance metrics to identify opportunities for improving processes and procedures. Assists and supports Director - Medical Operations in operations and administration of contracts, overseeing the day-to-day activities of clinical teams. Communicates regularly and serves as a liaison with government agencies, regulatory bodies, and other external stakeholders to ensure transparent and compliant company programs.
Essential Functions:- Supervises teams to monitor and ensure compliance with relevant laws, regulations, and organizational policies. Collaborates inter-departmentally to prioritize compliance efforts and address regulatory requirements.
- Implements measures to mitigate potential risks to program integrity.
- Ensures best practices are followed to maintain and enhance the quality of nursing activities, ensuring they meet established standards and guidelines.
- Engages with governmental and law enforcement stakeholders as required.
- Acts independently to assess existing nursing processes for efficiency, effectiveness, and compliance.
- Collaborates with other departments, stakeholders, and external entities to ensure a comprehensive approach to program integrity and patient care.
- Works closely with the Supervisor - Clinical Review's staff to manage workload, ensuring timeliness and quality of service delivery.
- Maintains accurate documentation of nursing program activities and produces regular reports on metrics related to program integrity, compliance status, and quality.
- Instructs nursing staff on compliance and integrity matters, ensuring they understand and adhere to policies and procedures. Provides job-specific orientation and training as needed.
- Manages team performance through regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development. Provides job specific orientation and training when called upon.
Level of Supervision Received:Drives work independently and escalates questions and issues, as needed
Education (can be substituted for experience):Minimum Bachelor's Degree required
Work Experience (can be substituted for education):5 - 7 years of experience required; 8 - 11 years preferred
Certification(s):Current, active and non-restricted RN licensure required
Coding certification preferred
