Summary of Position:

Manage, monitor and track compliance of the UM, CM, MRU, MCRU adherence to Plan, regulatory, and accreditation requirements functions include but are not limited to appeals, case management, , utilization management. Participate in planning and implementing strategies that provide direction and subsequent monitoring of the UM, CM, MRU, MCRU team functions including assessment of potential new processes and existing processes. Interact with and educate the UM, CM, MRU, MCRU management team, to review Corrective Actions Plans from/for Compliance and ensure that they are being managed and adhered to. Oversee the monthly Key Performance Indicator (KPI), auditing the results and providing feedback to the UM, CM, MRU, MCRU areas on areas that are not meeting Compliance thresholds. Work with Reporting area to develop and maintain reports that provide data from the system and apply it to timeframes/standards. Work with the Delegates and vendors.

Responsibilities:

Audit, monitor and track compliance of the UM, CM, MRU, MCRU teams adherence to the Plan, regulatory, and accreditation requirements functions include but are not limited to appeals, case management, utilization management,. This entails reviewing reports against regulatory requirements, looking for trends, notifying management of any trends, and then tracking their responses/actions to ensure the negative trends do not continue. Participate in planning and implementing strategies that provide direction and subsequent monitoring of the UM, CM, MRU, MCRU team functions including assessment of potential new processes and existing processes. Track UM, CM, MRU, MCRU compliance using the dashboard/matrix, and other organizational and department tools including loading material for organizational use onto Sharepoint. Oversee and track audit reports and responses, including changes to any policies, procedures and other pertinent information (such as training and attestations) in a central corporate location This includes but is not limited to tracking and maintaining organization of documents including audit schedule, dashboard matrix, and team audit tools, CAPS, completed and incomplete audits, and other functions and processes to ensure efficiency within the Plan. Work with Reporting area to develop and maintain reports that provide data from the system and apply it to timeframes/standards. Uploading reports for Compliance on a monthly basis. Work with the Delegates/vendors and the top 5% report to request/review members that are being submitted for Case Management

Qualifications:

Associates degree desired, Bachelor’s degree preferred Years of experience can be substituted for years generally required for a degree Active, unrestricted Nursing License (RN or LPN) required Possess at least 4 to 6 years of experience in a managed care environment including familiarity with auditing, accreditation, compliance, Quality, or delegation or UM experience required Knowledge of accreditation standards, and regulatory standards such as NYSDOH and CMS preferred Experience within an operation that addresses complex relationships and multiple stakeholders with conflicting goals and priorities with diverse needs and skill sets required Strong problem solving and negotiating skills paired with strong attention to detail required Knowledge of utilization management process, case management process and, accreditation and regulations as applicable to managed care required Exercise discretion and maintain confidentiality required Ability to independently manage multiple tasks or projects simultaneously to successful completion required Remain highly organized and adhere to processes, policies and procedures required Excellent interpersonal skills, professionally communicate verbally in person, via telephone, and in writing Proficient in understanding and in use of Word, Excel, SharePoint, PowerPoint and Outlook, including excellent working knowledge of MS Office applications preferred Highly self-motivated and self-directed independent thinker while being a resource and strong and flexible team player required Additional Information Job Type: Standard Schedule: Full-time Employee Status: Regular Requisition ID: 2405B Hiring Range: $62,200 - $95,000