- Responsible for coordinating program integrity-related reviews with the medical necessity review team responsible for conducting medical necessity reviews, ensuring services claimed are medical necessary and documentations supports paid claims. This role shall ensure that all recoveries are made within agency rules & regulations, including National Correct Coding Initiative (NCCI) guidelines and shall serve as the NCCI subject matter expert for the Bureau of Program Integrity and Compliance.
- Ensures business rules and practices are followed for all major processes in order to ensure standardization, consistency and compliance.
- Manages department staff, anticipating needs, monitoring performance, and making recommendations to senior management.
- Develops and oversees staff training and capacity building efforts
- Supports project management in program design and identification of needs
- Responsible for ongoing staff training and development, manage quality assurance function and implement action plans to achieve team goals.
- Assists in reviewing a provider's clinical documentation, as well as participating in and producing summaries of hearings as needed.
- Coordinates with law enforcement, county children's services, adult protective units, county board of developmental disabilities, or any other entity as needed.
- Manages team's documentation of all investigative activities.
- Conducts and documents interviews with individuals who may have relevant information.
- For incidents involving abuse, neglect, exploitation, or suspicious death, attempt to complete face-to-face (in person or via web technology) interviews to evaluate the credibility of the witnesses
- Ensures maintenance of standard operating procedures.
- Previous work experience performing medical records reviews and/or healthcare and fraud investigations.
- 2-5 years of experience as a utilization review manager conducting, directing, or leading medical necessity reviews of Medicaid managed care and/or program integrity investigations preferred
- Previous supervisory experience required.
- Excellent written and verbal communication, interpersonal, and client-facing skills.
- Ability to work across all levels of management and staff, including subcontractor, client, clinical, and data analytic operations teams.
- Ability to successfully monitor and ensure the quality of data analytic and clinical review activities.
- Knowledge of claims and medical record review data across provider service types.
- Ability to delegate and manage caseload across clinical teams.
- Ability to understand and interpret federal and state laws and regulations, including support in claim and investigation, and appeal processes.
- Strong Microsoft Office applications skills; preferably with Excel, Word, Outlook, and Access.
- Hybrid Remote Schedule (1-2 days in office)
- Candidates MUST live within 2 hour driving distance to the Des Moines, IA office
- Candidates MUST be a resident of Iowa
- Travel may be required up to 10% for client meetings
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Program Integrity - Cedar Rapids, United States - Public Consulting Group
Description
Overview
Public Consulting Group LLC (PCG) is a leading public sector solutions implementation and operations improvement firm that partners with health, education, and human services agencies to improve lives.
Founded in 1986, PCG employs approximately 2,000 professionals throughout the U.S.-all committed to delivering solutions that change lives for the better.
The firm is a member of a family of companies with experience in all 50 states, and clients in six Canadian provinces and Europe.
PCG offers clients a multidisciplinary approach to meet challenges, pursue opportunities, and serve constituents across the public sector. To learn more, visitResponsibilities
Education:
RN or LPN, with active Iowa Nursing licensure, BSN preferredExperience:
Required Skills:
Working Conditions:
Remote Work Statement:
This position is a remote, work from home position.
PCG is a remote-friendly organization and is committed to creating a culture where remote work remains a vital part of the company's success.
To be successful in a remote work role at PCG, you must:* be available during your set working hours.
* have a safe, private, and distraction-free environment in which to complete your work, and
* be able to give your full attention to the completion of your PCG job duties.
Some travel to the office or elsewhere may be required for team meetings, client meetings, etc.
We are accepting applications on an ongoing basis until filled.
#LI-remote
Compensation
Compensation for roles at Public Consulting Group varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience.
$80,000-$100,000 and a potential discretionary bonus of up to 10%. In addition, PCG provides a range of benefits for this role, including medical and dental care benefits, 401k, PTO, parental leave, bereavement leave.
EEO Statement
Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion.
We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences.
At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications.
We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law.
PCG will not tolerate discrimination or harassment based on any of these characteristics.PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.
