Associate Manager-Clinical Scope & Code Compliance (Remote)

American Specialty Health Incorporated

65d•$56,700 - $72,000•Remote

About The Position

American Specialty Health Incorporated (ASH) is seeking an Associate Manager-Clinical Scope & Coding Compliance to join our Clinical Quality Administration department. The primary purpose of this position is to coordinate and support the processes within the Clinical Quality Administration Department, including the management of the practitioner scope-of-practice database to ensure ASH has the most up to date information on the scope of practice of various complementary and allied healthcare professionals. CQA support includes cross-functional training and support, as needed, to all CQA functions that require clinician management.

Requirements

Bachelor’s Degree or equivalent experience required. If equivalent experience, High School Diploma required.
2 years of experience in healthcare administration, managed health care plan operations, managed care and/or health insurance compliance experience required.
Specific experience to include utilization management review, compliance research, or scope of practice review required.
Demonstrated writing proficiency required.
Demonstrated English writing proficiency required.
Ability to determine the medical necessity of services based on data provided and ASH guidelines.
Able to communicate effectively with staff ranging from entry level to senior level management.
Extreme attention to detail is required in all functions of this position.
General knowledge of CPT, ICD and HCPC coding.
Understanding of general health care insurance (e.g., DOI, DMHC, CMS/Medicaid).
Able to research, summarize and provide analysis of scope of practice laws and regulations.

Nice To Haves

Bachelor’s Degree in Health Care Policy or Administration preferred.
Experience with health insurance, managed care contracts, or accreditation preferred.
Experience in Quality Improvement data analysis preferred.
Paralegal or legal secretary experience preferred.
Knowledge of health care and/or legal terminology preferred.
Knowledge of ASH systems, policies and procedures preferred.
DC - Doctor of Chiropractic preferred.
MD - Physician - State Licensure preferred.
PT - Physical Therapist preferred.
OT - Occupational Therapist – Registered preferred.
ST - Speech Therapist preferred.
LAC - Licensed Acupuncturist preferred.
RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred.
Valid clinical license (DC, MD, PT, OT, ST, DPM, LAc or RN) preferred.

Responsibilities

Assist in the management of Clinical Quality Administration functions within the organization (as directed by Senior Manager CQA, Director CQA or Senior Vice President (SVP) of Clinical Quality Administration.
Assists in management and is accountable for all activities within assigned scope of authority.
Ensures accuracy and productivity in project completion and works cooperatively with all internal departments and external contacts.
Achieves and exceeds company standards in management of quality management tasks.
Read and analyze legislative and regulatory language.
Draft memos and present to internal committees and workgroups.
Manages projects in support of department goals as assigned.
Knowledge and ability to research clinical issues, including scope of practice and clinical operations using various research resources (i.e. SAI360, Westlaw, StateNet, State Board websites).
Knowledge and ability to research state and federally sponsored insurance benefits such as Medicare and Medicaid issues, utilizing various research resources (i.e. Medicare website, State Medicaid Websites, Medicare Internet Only Manuals, NCCI look-up tool and manual).
Review Enacted Legislation, Regulatory Reports and RPC Bulletins, assess pertinent information and ensure management is apprised of important items and SOP grids are updated timely. Develop broader knowledge of NCQA and URAC accreditation requirements.
Support Key Process Teams presentations and action items as required by Senior Manager CQA, Director CQA or SVP of CQA.
Serve as resource to directors, managers, and staff relating to compliance and/or procedural inquiries.
Assist in review of Medical Necessity Review forms (MNR) as needed.
Manage the accuracy and confidentiality of quality-related communication and minutes.
Assist staff, as appropriate, in supporting the resolution of quality of care issues.
Attend meetings with customers when requested by Senior Manager CQA, Director CQA or SVP of CQA.
Support the development and writing of QIA’s and QI studies and presentation to appropriate committees for review and recommendations.
Support company wide education in CQI processes by participating with appropriate Key Process teams as needed.
Serve as resource to directors, managers, and staff relating to scope of practice and/or procedural inquiries.
Performs other duties as assigned.
Complies with all policies and standards.