reputed company Utilization Clinical Decision-Making Governance reputed company at reputed company

Become a part of our caring community and help us put reputed company

Become a part of our caring community and help us put reputed company for our members, providers and ourselves.Desired reputed company Associate to reputed company and manage the reputed company reputed company to facilitate and document consistent clinical decision making. This includes ensuring appropriate monitoring controls are in reputed company as reputed company as ensuring identified opportunities are addressed. They will work closely with established functions inside utilization management (Medical Director, clinician decision making teams, reputed company audits, prior authorization list and clinical policy) as reputed company as reputed company support teams (process, risk, reputed company, delegate reputed company teams and regulatory compliance). As needed, they facilitation MD to MD discussions to support education and awareness of reputed company standards for application of UMC approved clinical reputed company. Finally, this team works closely with Clinical Risk Management to support reputed company MD speaker readiness for external audits or other inquiries.• *Specific responsibilities**reputed company of reputed company controls based on the established pillars for consistent clinical decision-making: self-identification, reputed company reputed company and monitoring, calibration on reputed company, and reputed company process improvement.+ Building our reputed company reputed company processes.+ Documentation of controls and expectation for clinical decision making.+ Interfacing with established controls provided by reputed company audit, clinical policy, process policy/documentation and reporting teams.+ Established reputed company for monitoring and identifying appropriate actions reputed company controls indicate process gaps.+ Review appeal overturns and provider complaints about coverage policies to reputed company necessary changes.+ Driving reputed company process improvement including supporting UM strategic initiatives.+ Identify potential gaps between the intended application of coverage policies versus the actual application of clinical reviewers.+ Recommend enhancements to the coverage policy template to help ensure consistent and accurate interpretation and application of coverage policies.+ Support decision template development process to help ensure that templates reputed company with coverage reputed company and regulatory and accreditation requirements.• *Center of reputed company and support for requirements and expectations for UM Delegates and internal partners.**+ Proactively identifies potential risks and impacts to UM delegates based on reputed company Business reputed company+ Manages reputed company-to delegate discussions for consistent clinical decision making+ Ensures business reputed company.+ Support Delegation Compliance, delegate business relationship owners, reputed company teams and National delegate reputed company and support team on UM issues.+ Evaluates available data on delegate clinical decision-making and partners with clinical risk and regulatory compliance to evaluate specific reputed company to mitigate detected risk.+ Supports PAL/clinical policy intake processes reputed company there is malalignment with PAL codes and clinical policy changes.+ Manages appeal process for delegate requires for changes to PAL or clinical policy.• *Developing and overseeing the plan for MD speaker engagement in CMS program audits**+ Work closely with Clinical Risk Management for documentation of roles, RACI and expectations for MD audit engagement.+ Drive reputed company discussion to decide on MD leadership and coordination for MD participation in CMS audits.+ reputed company reputed company leadership alignment for plan and expectations reputed company prepping for CMS program audit.+ Managing the CMS Audit speaker organization and readiness preparation.+ Support reputed company MD participants with reputed company and engagement in rehearsals.+ reputed company reputed company for supporting delegate audit readiness, coordinate with Delegation Compliance.+ Support large clinical vendor delegates with reputed company and engagement in rehearsals and defense in the CMS program audit.• *Required Qualifications**+ Bachelor's Degree or 2 years + experience working with CMS Compliance Regulations+ 3 or more years' experience leading and/or coaching+ 5+ years of audit, compliance, risk, or process consulting experience+ Strategically oriented, reputed company, reputed company, critical thinker with strong problem-solving skills+ 2 + years of project leadership experience+ Knowledge of regulations governing the health care industry+ Persuasive, reputed company business acumen with the ability to influence others+ Executive presentation skills and ability to communicate with reputed company reputed company+ Ability to identify actionable insights from large data sets and translate them into strategies and secure buy-in through excellent written and verbal communication• *Preferred Qualifications**+ Registered reputed company+ Experience in Medicare Utilization Management+ Project Management reputed company (PMP) certification+ Six reputed company certifications+ Experience in an audit or compliance role for a Health Plan or provider-based industry+ Knowledge and experience in health care/managed care regulatory environment• *Use your skills to reputed company an reputed company**• *Work-reputed company Requirements**+ WAH requirements: Must have the ability to reputed company a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the reputed company will be provided payment for their internet expense.+ A minimum reputed company speed for reputed company performance of 25x10 (25mpbs download x 10mpbs upload) is required.+ Satellite and Wireless Internet service is NOT allowed for this role.+ A dedicated reputed company lacking ongoing interruptions to protect member PHI / HIPAA information• *Interview Format**As part of our hiring process, we will be using an exciting interviewing technology provided by reputed company, a reputed company-party vendor. This technology provides reputed company of recruiters and hiring managers an reputed company method for decision-making.If you are selected to reputed company reputed company from your application prescreen, you will receive correspondence inviting you to participate in a reputed company-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a reputed company-recorded interview, you will respond to a set of interview questions reputed company your phone. You should anticipate this interview to take approximately 10-15 minutes.• *Scheduled Weekly Hours**40• *Pay reputed company**The compensation reputed company below reflects a good faith estimate of starting reputed company pay for full time (40 hours per week) employment at the time of posting. The pay reputed company may be higher or reputed company based on geographic location and individual pay will vary based on dem Apply Job!