Associate Manager-Clinical Scope & Code Compliance (Remote)

American Specialty Health Incorporated (ASH) is seeking an Associate Manager-Clinical Scope & Coding Compliance to join our Clinical Quality Administration department.

The primary purpose of this position is to coordinate and support the processes within the Clinical Quality Administration Department, including the management of the practitioner scope-of-practice database to ensure ASH has the most up to date information on the scope of practice of various complementary and allied healthcare professionals. CQA support includes cross-functional training and support, as needed, to all CQA functions that require clinician management.

Remote Worker Guidelines

• Remote Worker Guidelines: This position will be trained remotely and must be able to work from home (WFH) in a designated work area with company-provided technology equipment. This WFH position requires you have a stable connection to your Internet Service Provider with the ability to participate by video in online meetings over a reliable and consistent network. The internet connection must have a consistent 50 down/10 up Mbps minimum internet speed. 100 down/20 up is recommended to support higher quality video meetings.

Responsibilities

• The work will consist of the following activities:
  • Assist in the management of Clinical Quality Administration functions within the organization (as directed by Senior Manager CQA, Director CQA or Senior Vice President (SVP) of Clinical Quality Administration.
  • Assists in management and is accountable for all activities within assigned scope of authority.
  • Ensures accuracy and productivity in project completion and works cooperatively with all internal departments and external contacts.
  • Achieves and exceeds company standards in management of quality management tasks.
  • Read and analyze legislative and regulatory language.
  • Draft memos and present to internal committees and workgroups.
  • Manages projects in support of department goals as assigned.
  • Knowledge and ability to research clinical issues, including scope of practice and clinical operations using various research resources (i.e. SAI360, Westlaw, StateNet, State Board websites).
  • Knowledge and ability to research state and federally sponsored insurance benefits such as Medicare and Medicaid issues, utilizing various research resources (i.e. Medicare website, State Medicaid Websites, Medicare Internet Only Manuals, NCCI look-up tool and manual).
  • 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 resource to directors, managers, and staff relating to compliance and/or procedural inquiries.
  • Assist in review of 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 resource to directors, managers, and staff relating to scope of practice and/or procedural inquiries.
• Performs other duties as assigned.
• Complies 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.
• Ability to determine the medical necessity of services based on data provided and ASH guidelines.
• 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.

Core Competencies

• Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
• Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
• Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
• Ability to effectively organize, prioritize, multi-task and manage time.
• Demonstrated accuracy and productivity in a changing environment with constant interruptions.
• Demonstrated ability to analyze information, problems, issues, situations, and procedures to develop effective solutions.
• Ability to exercise strict confidentiality in all matters.

Mobility

• Primarily sedentary, able to sit for long periods of time.

Physical Requirements

• Ability to see, speak, and hear other personnel and/or objects. Ability to communicate both in verbal and written form. Ability to travel within and around the facility or Work from Home (WFH) environment. Capable of using a telephone, computer keyboard, and mouse. Ability to lift up to 10 lbs.

Environmental Conditions

• Work-from-home (WFH) environment.

American Specialty Health is an Equal Opportunity/Affirmative Action Employer.

All qualified applicants will receive consideration for employment without regard to sex (including pregnancy, childbirth, related medical conditions, breastfeeding, and reproductive health decision-making), gender, gender identity, gender expression, race, color, religion (including religious dress and grooming practices), creed, national origin, citizenship, ancestry, physical or mental disability, legally-protected medical condition, marital status, age, sexual orientation, genetic information, military or veteran status, political affiliation, or any other basis protected by applicable local, federal or state law.

Please view Equal Employment Opportunity Posters provided by OFCCPhere.

If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact our Human Resources Department at (800) 848-3555 x6702.

ASH will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company's legal duty to furnish information.

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