Description:
GENERAL SUMMARY
- Provides ongoing and random qualitative and quantitative analysis of the business process, clinical systems/tools, and staff competencies using organizational performance measurements to ensure compliance with government regulations and corporate policy. Reviews and evaluates internal controls are in place to ensure ongoing compliance.
- Identifies, documents, and reports any transaction errors in a timely manner to ensure prompt resolution. Tracks and trends audit results, providing feedback to management. Recommends corrective action and facilitates the implementation of remedial and process improvement plans.
- Develops and conducts medical management staff training based on outcomes of clinical audits. Implements training programs to increase role specific consistencies and efficiencies related to process work flows.
- Measures outcomes of clinical staff training and identifies key findings to insure effective alignment of training content and method of delivery with business objectives and staff performance requirements.
- Promotes continuing compliance with accreditation and/or applicable regulatory body requirements including but not limited to: company’s ethical, fraud, abuse, and compliance policies and expectations, utilization management policies, procedures and workflows, key accreditation standards, and HIPAA regulatory standards related to use of PHI. Facilitates communication of relevant findings to corporate Compliance Department and/or Corporate Privacy/Security Officer.
- Performs other duties as required.
Qualifications:
- Clinical licensure required based on clinical sector supported.
- General Medical Management requires current RN license in state where job duties are performed.
- Medicaid Clinical Audit requires a current LPN or RN license in state where job duties are performed.
- Behavioral Health Medical Management requires professional licensure in state where job duties are performed; Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC), licensed psychologist, or Registered Nurse (RN).
- Previous (3-5 years) experience in a managed care clinical operations environment (utilization management, case management, and/or behavioral health case management) required.
- Previous experience developing and conducting training programs.
- Experience in curriculum development, instructional design, and adult learning needs assessment.
- Excellent verbal and written communication skills.
- Strong data analysis and report preparation skills.
- Ability to use standard corporate software packages and corporate applications.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Casselberry, FL, US
Other Locations: Austin-Texas-United States,St. Louis-Missouri-United States,Louisville-Kentucky-United States,
Organization: 51000 - MHNet Specialty Services, LLC
Schedule: Full-time
Job Posting: 2013-04-05 00:00:00.0
Job ID: 1311275
GENERAL SUMMARY
Responsible for conducting audits of current processes, reports, and procedures to identify process improvements and issue resolutions. Develops and conducts medical management staff training based on outcomes of clinical audits.
ESSENTIAL RESPONSIBILITIES
- Provides ongoing and random qualitative and quantitative analysis of the business process, clinical systems/tools, and staff competencies using organizational performance measurements to ensure compliance with government regulations and corporate policy. Reviews and evaluates internal controls are in place to ensure ongoing compliance.
- Identifies, documents, and reports any transaction errors in a timely manner to ensure prompt resolution. Tracks and trends audit results, providing feedback to management. Recommends corrective action and facilitates the implementation of remedial and process improvement plans.
- Develops and conducts medical management staff training based on outcomes of clinical audits. Implements training programs to increase role specific consistencies and efficiencies related to process work flows.
- Measures outcomes of clinical staff training and identifies key findings to insure effective alignment of training content and method of delivery with business objectives and staff performance requirements.
- Promotes continuing compliance with accreditation and/or applicable regulatory body requirements including but not limited to: company’s ethical, fraud, abuse, and compliance policies and expectations, utilization management policies, procedures and workflows, key accreditation standards, and HIPAA regulatory standards related to use of PHI. Facilitates communication of relevant findings to corporate Compliance Department and/or Corporate Privacy/Security Officer.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Clinical licensure required based on clinical sector supported.
- General Medical Management requires current RN license in state where job duties are performed.
- Medicaid Clinical Audit requires a current LPN or RN license in state where job duties are performed.
- Behavioral Health Medical Management requires professional licensure in state where job duties are performed; Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC), licensed psychologist, or Registered Nurse (RN).
- Previous (3-5 years) experience in a managed care clinical operations environment (utilization management, case management, and/or behavioral health case management) required.
- Previous experience developing and conducting training programs.
- Experience in curriculum development, instructional design, and adult learning needs assessment.
- Excellent verbal and written communication skills.
- Strong data analysis and report preparation skills.
- Ability to use standard corporate software packages and corporate applications.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Casselberry, FL, US
Other Locations: Austin-Texas-United States,St. Louis-Missouri-United States,Louisville-Kentucky-United States,
Organization: 51000 - MHNet Specialty Services, LLC
Schedule: Full-time
Job Posting: 2013-04-05 00:00:00.0
Job ID: 1311275