The Clinical Compliance Coordinator goal is to improve accuracy and quality of the clinical process.  This position is responsible for assisting the Manager of Clinical Compliance with oversight of CMS, BMS, NCQA, ERISA, Department of Labor regulations, monitoring of internal processes, conducting Interrater review of navigators, internal and external audits and producing reports to ensure clinical compliance and accuracy.   They will have the ability and be expected to initiate change and positively impact the accuracy and efficiency of The Health Plan’s processes by recommending actions that address error trends and root-cause of error found during Interrater and quality audits.

Required:

1. Bachelor's degree in a healthcare related field.
2. Must have at least one (1) year of managed care experience.
3. Preferred certification in managed care or case management or pursuit of certification within 2 years of obtaining position.

Desired:

1. Must possess excellent oral, written, telephonic and interpersonal skills, balancing an independent and teamwork environment.
2. Must possess a superior work ethic and a commitment to Excellence and Accountability.
3. Strong Clinical and Health Services knowledge base.
4. Solid working knowledge of operational processes.
5. Detailed oriented, with proven time management and organization skills (including the ability to engage in multiple tasks and meet deadlines/standards).
6. Awareness of applicable state and federal statutes (CMS, BMS, Department of Labor, NCQA) regulations, clinical coverage guidelines and Policies & Procedures.
7. Strong analytical and problem-solving skills.
8. Must possess ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues.
9. Be a positive role model and work independently in conjunction with co-workers of all levels.
10. Must possess proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems.

Responsibilities:

1. Displays comprehensive understanding of all related Utilization Management (UM) processes and associated programs and systems.
2. Assists the Supervisor of Government Productions with troubleshoots daily prior-authorization concerns and related questions.
3. Assists with remediation plans regarding referral process, as needed. CMS & BMS guidelines.  
4. 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).
5. Collaborates and shares knowledge and expertise with peers, supervisors, and other Health Plan staff.
6. Assists the Manger of Clinical Compliance with reporting and audits to ensure accuracy of clinical performance against regulatory requirements.
7. Performs daily, monthly, quarterly, and annual reporting of THP and delegated UM key performance indicators, as directed.
8. Completes reporting in the CMS On-line Monitoring Tool (OMT) and SharePoint as assigned by the compliance department.
9. Assists the Manager of Clinical Compliance with the creation and completion of the NCQA and Clinical Compliance Work Plans, which provide qualitative and quantitative analyses of Key Performance Indicators and NCQA standards.
10. Identifies opportunities for improvement in systems, processes, functions, reporting, programs, procedures and makes recommendations to the Manager of Clinical Compliance.  
11. Serves as assigned on departmental or company committees.
12. Assists in updating the Clinical Compliance Calendar.
13. Prioritizes assignments appropriately and maintains flexibility as new priorities arise.

Equal Opportunity Employer

The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.