Associate Manager-Clinical Scope & Code Compliance (Remote)

Responsibilities

• Aid in managing Clinical Quality Administration functions within the organization.
• Support the management and accountability for all activities within assigned scope of authority.
• Ensure accuracy and productivity in project completion and cooperate with internal departments and external contacts.
• Achieve and exceed company standards in managing quality management tasks.
• Read and analyze legislative and regulatory language.
• Draft memos and present to internal committees and workgroups.
• Manage projects in support of department goals as assigned.
• Research clinical issues, including scope of practice and clinical operations using various research resources.
• Research state and federally sponsored insurance benefits such as Medicare and Medicaid issues, utilizing various research resources.
• 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 a resource to directors, managers, and staff relating to compliance and/or procedural inquiries.
• Assist in reviewing 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 a resource to directors, managers, and staff relating to scope of practice and/or procedural inquiries.
• Comply with all policies and standards.

Qualifications

• Bachelor’s Degree or equivalent experience required.
• If equivalent experience, High School Diploma required.
• Bachelor’s Degree in Health Care Policy or Administration preferred.
• 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.
• Experience with health insurance, managed care contracts, or accreditation preferred.
• Experience in Quality Improvement data analysis preferred.
• Paralegal or legal secretary experience preferred.
• Demonstrated writing proficiency required.
• Knowledge of health care and/or legal terminology preferred.
• Knowledge of ASH systems, policies and procedures preferred.
• 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.
• Demonstrated English writing proficiency required.
• Able to communicate effectively with staff ranging from entry level to senior level management.
• 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.