Unique opportunity to provide quality oversight of utilization management “UM” functions in compliance with a rapidly growing integrated healthcare organization in Southern Florida.
Can be 100% REMOTE.
Will consider a FL Compact RN license
The ideal candidate will ensure that the UM procedures and delegation expectations are synchronized and administered with appropriate and timely quality of care and services.
- Facilitate continuous improvement in UM/QM and clinical operations through collaboration with other departments and contracted health plans and continuous monitoring of clinical metrics through QA activities
- Ensures departmental and intra-departmental compliance standards with regulatory and accreditation agency are being met
- Manage development of policies and procedures related to QA activities, reviews, and delegation oversight requirements
- Manage regulatory audits, including preparation and monitoring of any corrective plans, timely collections of reporting with data analysis to meet quality and delegation requirements
- Fulfill and maintain compliance with federal, state, and NCQA requirements including corrective action plan (CAP), monitoring CAP activities, and providing education and tools as needed
- Collaborate with health plans, downstream provider groups, and accreditation authorities as necessary
- Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, and completing all requirements for ongoing licensures and certifications
- Facilitate QA-related collaborative interaction with health plans, downstream provider groups, and accreditation authorities
- Monitor compliance with provider organization quality background investigation and subsequent report to Credentialing Committee
- Superlative organizational, writing, and communication standards
- Self-motivated with the ability to work autonomously
- Working knowledge of Outlook, Excel, Word, and Adobe Acrobat Pro
- Detail-oriented with the ability to work on multiple, competing, priorities and is extremely organized
- Possess analytical, verbal, and written communication skills, able to interface with UM and interrelated process owners and maintain effective working relationships with others
- Bachelor’s degree with a focus in healthcare administration; Master’s degree (MHA) preferred
- Minimum of three years of experience in a health plan/ hospital setting primarily in UM/compliance function
- Some home healthcare experience preferred
- Experience with Utilization Management or Quality Improvement Plans (QIP) with InterQual and/or Milliman, CMS, and peer reviewed guidelines required
- Valid Registered Nurse (RN) REQUIRED