Supervisor, Clinical Compliance (RN)

Guidehealth•Rockford, IL

3d•Remote

About The Position

In this position you will be leading a team of independent and autonomous Clinical Compliance Auditors and Specialists to ensure we follow the outlined Utilization Management (UM) and Population Health Management (PHM) Plan and Member Service Agreement (MSA) clinical requirements. With the assistance of the Clinical Compliance Manager, UM Manger, and PHM Manager you will create and develop annual goals to show clinical compliance is being met in real time by cross collaboration with the Leadership Team. You will strive for continuous improvement and an excellent work balance to produce top-notch results.

Requirements

Registered Nurse with an active and unrestricted license in IL.
Three to five years of experience in leading UM and PHM plan and MSA requirement changes.
Experience in a managed care environment with multiple clients.
Experience in the UM and PHM process and managed care.
Strong organizational, written and presentation skills necessary.
High analytical ability to define and describe complex problems.
Ability to prioritize and react based on rapidly changing business needs.
Proficient in the use of medical terminology and nationally recognized medical criteria.
Computer skills including Microsoft Word, Excel, Outlook, PowerPoint etc.

Nice To Haves

Claims processing experience
Coding certificates are a plus

Responsibilities

Supervising and directing the day-to-day operations of the clinical compliance auditors and specialists.
Serving as the clinical services liaison to senior management and other company leaders.
Assisting in developing coordinated and efficient companywide team processes.
Assisting with coordinating orientation, training, continuing education, and ongoing performance monitoring for clinical compliance auditors and other departments as required.
Working with Leadership to promote the staff’s continued professional growth and education.
In conjunction with the Compliance Manager, UM Manager, and PHM Manager, overseeing and assisting with developing and managing the agenda and meeting minutes for the monthly utilization management data reported to the Independent Physician Association (IPA) UM Committee.
Assisting with facilitating UM and PHM Plan development and adherence.
Identifying UM and PHM Plan requirements and assisting in creating auditing guidelines to ensure clinical staff continue meeting the minimum requirements, including quarterly, semiannual, and annual submission requirements set forth in the UM and PHM Plan.
Serving as a secondary reviewer to ensure adherence to the denial process and all denial compliance audit requirements.
Reviewing and ensuring all documentation is submitted in a timely manner.
Supporting the maintenance of confidentiality related to all computer programs, medical records, and other data.
Applying critical thinking skills and decisive judgment while working with minimal supervision.
Ensuring meeting minutes are completed, signed, and uploaded in accordance with UM and PHM Plan requirements.
Assisting with all internal and external audit reviews and submissions.
Completing monthly 30/30 reviews with the clinical compliance auditors and specialists.
Maintaining a professional appearance during on-camera meetings.
Performing other duties as assigned.