Clinical Compliance Program Manager

WellSky

1d•Remote

About The Position

This job is responsible for ensuring compliance with WellSky's Utilization Management and Compliance Program by serving as a clinical expert on state and federal regulations. The scope of this job includes analyzing and presenting data to establish best practices across post-acute health care settings, including LTACHs, IRFs, SNFs, and Home Health facilities. We invite you to apply today and join us in shaping the future of healthcare!

Requirements

At least 4-6 years relevant work experience
Advanced working knowledge of CMS UM audits.
At minimum, 2-3 years of compliance experience focused on CMS and health plan audits.
At minimum, 1-2 years of implementing CMS final rule changes and managing change management of processes.
Bachelor's Degree or equivalent work experience
Must work in accordance with applicable security policies and procedures to safeguard company and client information.
Must be able to sit and view a computer screen for extended periods of time.

Nice To Haves

Active, unrestricted license: RN, PT, OT or SLP, with a bachelor’s degree in a related field or a combination of education and experience that includes pertinent clinical experience and advanced working knowledge of CMS standards and guidelines.
Experience with NCQA audits.
Must be able to prioritize, plan and handle multiple tasks and demands simultaneously, with competing deadlines.
Excellent in manipulating and sorting data for analytics and reporting.
Prior experience owning client compliance SLAs and ensuring success in meeting SLA requirements.

Responsibilities

Facilitate activities related to performance measurement and outcomes, ensure the organization meets CMS, NCQA, and other regulatory standards, stay updated on relevant regulatory changes, and support their integration into practices.
Comply with state, federal, and organizational standards by assisting in the development and enforcement of policies aligned with Utilization Management and Compliance requirements.
Complete and successfully submit CMS reports: ODAG, Part C, Reopening, and Complaints and Grievance Reports.
Conduct Root Cause Analysis (RCA) with Operational teams.
Conduct regular compliance audits based on CMS UM standards for expedited, standard and other case statuses.
Develop and guide the implementation of internal audit protocols in compliance with CMS regulations and NCQA standards and contribute to the consistency of clinical documentation and decision-making processes.
Generate and validate reports to monitor performance and compliance across health plan contracts, ensuring accuracy and alignment with requirements.
Prepare for regulatory, accreditation, and contractual audits, and contribute to the remediation and documentation of audit findings.
Perform other job duties as assigned.