Clinical Compliance, Sr. Leader, Clinical Regulatory and Delegation Oversight
Status: Full-time, Exempt: Yes
This position will provide direct oversight of Clinical compliance activities, including delegation oversight functions, for Health Management departments. This encompasses Utilization Management, Behavioral Health, and Case Management, with expected future expansion into Appeals and Pharmacy. This individual will be the point person for effectively communicating clinical regulatory and accreditation changes or updates and providing education to Health Management (and delegates) regarding the interpretation of those changes. Monitoring of all clinical regulatory activities and/or changes will be as part of this individual’s oversight. Periodic standard and targeted clinical internal monitoring will be conducted and reported to respective Health Management departments, with corrective action plans developed and monitored as needed. Case files for all external audit requests will be prepared, including summary reports and risk assessments for each audit, and overall assessment communicated to respective clinical departments pre- and post-audit. Other duties include creating a centralized source for distributing information on laws, statutes, regulations, accreditation standards; maintaining and evaluating metrics on compliance activities (including root cause for any identified deficiencies) monitored by Clinical Compliance; and reviewing Health Management monthly/quarterly department submissions of compliance activities related to case timeframes, letter QC, etc. Occasional travel to other MVP locations. Performs other duties as required.
Bachelor’s degree in health-related field.
Master’s degree preferred
Registered Nurse or other healthcare clinical degree preferred
Eight (8) years managed care clinical experience, some of which should include compliance activities
Management experience required
Program development experience required
• In depth knowledge of NCQA standards, NYS DOH/DFS, VT DFR, and CMS managed care regulations related to Utilization Management, Case Management, Behavioral Health and Appeals. Includes excellent analytical skills related to the compliance duties related to these regulations.
• Project management including knowledge of database tracking, project timelines and adherence to establish workflows.
• Excellent oral and written communication skills. Demonstrated presentation skills.
• Ability to work independently and prioritize multiple assignments to meet deadlines.
• Demonstrated proficiency in Microsoft Office Suite.
• Experience with Facets, Macess and Care Radius preferred.
MVP Health Care is an Affirmative Action/Equal Opportunity Employer (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at firstname.lastname@example.org.
- Job Family Medical Management/Clinical
- Pay Type Salary
- Headquarters Office, 625 State Street, Schenectady, New York, United States of America