Quality Control Senior Manager

HCA Healthcare • Nashville, TN

113d

About The Position

HCA Healthcare is seeking a Quality Control Senior Manager to ensure the quality and accuracy of clinical reviews. This role is pivotal in identifying and addressing payer medical policy issues, supporting the regulatory compliance team, and enhancing the overall quality of clinical processes. The Senior Manager will analyze physician documentation, assist with quality control and oversight, and serve as a subject matter expert for educational programs. This position also involves active participation in leadership meetings and contributing to the onboarding of new physician advisors.

Requirements

• A minimum of 8-10 years of clinical experience is required.
• At least 2 years of leadership experience is preferred.
• Possess a strong clinical background, with preference given to candidates familiar with Medicare and Medicare Advantages Two-Midnight Rule.
• MD/DO preferred, particularly those no longer directly involved in patient care.

Responsibilities

• Perform rigorous quality control on clinical reviews, focusing on patient status, level of care, and length of stay to ensure accuracy and compliance.
• Proactively identify and address payer medical policies that lead to inappropriate denials, advocating for fair and accurate coverage.
• Provide crucial support to the regulatory compliance team in managing appeals and improving documentation to meet regulatory standards.
• Serve as a subject matter expert, guiding clinical appeal and peer-to-peer processes with expertise and insight.
• Actively participate in leadership meetings, contributing to strategic decision-making, and assist in the onboarding of new physician advisors.
• Conduct thorough quality control on accounts that have been reviewed, specifically focusing on patient status, level of care, and resolution of length of stay disputes.
• Respond promptly to requests for intervention from the centralized peer-to-peer team and others regarding denials and appeals processes.
• Analyze and monitor physician documentation to pinpoint areas needing improvement, ensuring comprehensive and accurate records.
• Support regulatory team members by highlighting accurate clinical documentation in appeals to substantiate the medical necessity of provided services.
• Coordinate ongoing educational programs to strengthen clinical appeal and peer-to-peer processes.
• Bring potential or actual problems in physician practices or documentation to the attention of regulatory leadership.
• Assist with the onboarding of new physician advisors, providing guidance and support.

Benefits

• Comprehensive medical coverage that covers many common services at no cost or for a low copay.
• Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans.
• 401(k) Plan with a 100% match on 3% to 9% of pay.
• Employee Stock Purchase Plan with 10% off HCA Healthcare stock.
• Family support through fertility and family building benefits with Progyny and adoption assistance.
• Referral services for child, elder and pet care, home and auto repair, event planning and more.
• Consumer discounts through Abenity and Consumer Discounts.
• Education assistance (tuition, student loan, certification support, dependent scholarships).
• Colleague recognition program.
• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence).
• Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Industry: Hospitals
• Education Level: Bachelor's degree