- Wheeling, West Virginia, United States
- 1+ years
Coordinate clinical compliance activities, oversee regulatory adherence, conduct audits, and produce reports to ensure accuracy and quality of clinical processes.
Responsibilities
- Displays comprehensive understanding of all related Utilization Management (UM) processes and associated programs and systems.
- Assists the Supervisor of Government Productions with troubleshooting daily prior-authorization concerns and related questions.
- Assists with remediation plans regarding referral process, as needed. CMS & BMS guidelines.
- Promotes and supports quality effectiveness of Healthcare Services by providing Staff education (monthly staff meetings) all-inclusive to referrals and compliance related to referrals in collaboration with Directors and manager(s).
- Collaborates and shares knowledge and expertise with peers, supervisors, and other Health Plan staff.
Requirements
- Bachelor's degree in a healthcare related field
- Nice to have: certification in managed care or case management
- Nice to have: pursuit of certification within 2 years