What are the responsibilities and job description for the Clinical Compliance Specialist position at Heritage Provider Network?
This role requires a fundamental understanding of Utilization Management (UM) and Case Management (CM), implementing organization methods that encompass monitoring of delegated health plan compliance which complies with all applicable regulations and statutes in adherence with the HPN Compliance Framework. This position is responsible for the development of and maintenance of P&Ps and training related to UM and CM.
Duties and Responsibilities:
- Develops, updates and maintains HPN UM & CM policies, procedures, program documents.
- Stays informed on UM & CM regulations, policies and procedures, job aids processes and changes.
- Supports UM & CM projects led by the Sr. Director Clinical Compliance Development.
- Tracks policy revision process through approval and distribution as appropriate.
- Ensures all assigned projects/monitoring audits are completed within required timeframe.
- Develops, updates and maintains HPN UM & CM compliance related training and materials to support UM & CM policies and procedures.
- Works collaboratively with HPN education team to leverage Learning Management system and deploy trainings to medical groups.
- Creates HPN-wide job aids and work flows as determined appropriate. Job aids will be developed in accordance with policies and procedures to ensure compliance.
- Maintains and/or works with managers to retain resources/evidence and keep tools updated based on current policy and procedure and job aids.
- Attend department meetings, in-services, trainings, and complete acknowledgement within required timeframe.
- Assists leadership in the development of year-end and mid year evaluation documents.
- Assist with the collection and preparation of documents for all regulatory audits.
- Provide leadership with project status updates, feedback, and appropriate reporting on key responsibilities and objectives
- Communicates effectively and interacts with the Affiliated Medical Groups, department managers, and staff.
- Other duties as assigned.
Corporate Expectations:
- Communicate verbally and in writing through appropriate channels.
- Proactively support and practice company mission, vision, and values.
- Follow all policies and procedures outlined in the Employee Handbook and otherwise.
- Adhere to all privacy, compliance and departmental policies and the corporate code of conduct.
- Know and follow safety standards.
- Follow attendance policies.
- Demonstrate honesty and integrity in everyday activities.
- Promote organizational goals.
- Be flexible and adaptable.
- Flexible work hours with some evening/weekend hours as needed.
Compliance Agreement:
Abide by the Company's Compliance Plan including its Standards of Conduct and all Compliance Policies and Procedures as listed on the Company's Intranet or Internet pages under "Compliance". This position further requires the Employee to act with the highest standards of integrity and professional ethics. This would include but is not limited to the expectation of integrity and professional ethics. This includes but is not limited to the expectation and requirement that the Employee immediately report any potential Compliance, Security or Privacy, or potential Fraud-Waste-Abuse violations or issues to the Compliance Officer, Compliance Hotline, and/or to any officer of the Company.
The pay range for this position at commencement of employment is expected to be between $42.00 and $51.00/hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience. The total compensation package for this position may also include other elements, including a sign-on bonus, restricted stock units, and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered. Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
Qualifications:
- Experience with Commercial, MA, AIP and Medi-Cal LOB. Knowledge and experience with compliance with NCQA, DMHC, DHCS and CMS requirements and regulations.
- Clinical Licensure: RN or LVN
- Managed Care experience required, health plan experience preferred.
- 3-5 years of UM and CM experience preferred.
- Training & Policy/Procedure writing experience required.
- Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and Power Point).
- Ability to deal with responsibility with confidential matters.
- Must have strong analytical, creative problem solving, and organizational skills and high personal ethics.
- Must be able to handle multiple projects at one time, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.
- Must have the ability to work with all levels of management and have the ability to develop positive working relationships with different divisions in the company.
Salary : $42 - $51