Manager, Clinical Compliance - Remote

Company Description

WHO IS GUIDEHEALTH? 

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. 

Job Description

As the Manager, Clinical Compliance, you will lead your staff to an exceptional performance level by giving quality objectives and opportunities to expand their knowledge of services, products, and troubleshooting techniques which will focus on improving performance and processes in an effort to better support customers and internal department procedures.   

WHAT YOU’LL BE DOING   

• Directly manage staff responsible for routine monitoring and audits of clinical procedures.
• Determine the Compliance Departments operational strategies by conducting assessments, capacity planning, and cost/benefit analyses; identifying and evaluating state-of-the-art technologies; defining user requirements; establishing technical specifications, production, productivity, quality and data entry standards; contributing information and analysis to organizational strategic plans and reviews with standard performance metrics.
• Maintains and improves Compliance Department processing operations by monitoring system performance; identifying and resolving problems; preparing and completing action plans; managing system and process improvement and quality assurance programs.
• Assessing and assigning workflow, coaching, counseling, and disciplining employees; administering scheduling systems and processes; communicating job expectations; planning, monitoring department measures, conducting staff performance conversations; enforcing policies and procedures.
• Ensure department audit scores meet requirements and consistently meet the expectations of the MSA and UM Plan.
• Play a key role in the development of the Annual UM and PHM Plans, MCG Guidelines and reports, and UM Packets.
• Understand and stay current with the clinical requirements of the MSA and UM Plan, ensuring Guidehealth remains compliant as well as meet client expectations. 
• Responsible for formulating professional development and educational plans for Compliance staff.
• Coordinate compliance activities with other internal functions alongside departments and managers.
• Conduct at minimum monthly meetings with direct reports and annual personnel reviews on staff performance.
• Attend client facing meetings as requested to discuss department statistics and measures.
• Maintain and report monthly and annual department Key Performance Indicators (KPI’s).
• Monitor internal and external processes to detect any practices that, either directly or indirectly, result in fraud, abuse or waste that results in unnecessary costs.
• Coordinate yearly notification of availability to care letters with third party vendors and client business managers.
• Assist with, and understand all department audits including Intake audits, Referral Coordinator audits, Population Health audits, Utilization Review audits and QI audits.
• Coordinate and review final Semiannual Audit Submissions
• Maintains professional appearance while on camera meetings.
• Other duties and responsibilities as assigned.

Qualifications

WHAT YOU’LL NEED TO HAVE 

• 2-5 years of direct management experience in Healthcare insurance platforms including clinical experience, professional analytics-related experience and experience working on/managing major projects.
• Minimum 1-3 years of experience in the healthcare or managed care industry, including clinical experience, auditing, professional analytics-related experience and experience working on/managing major projects.
• 1-3 years auditing experience in the healthcare industry.
• Prior experience with MCG CareWeb QI.
• CPT and ICD coding knowledge.
• Proficient with Microsoft programs (Word, Excel and Access) at an intermediate to advanced level.
• Must be organized, self-motivated, detail oriented, disciplined and a team player
• Demonstrates the ability to manage staff and multi-task with minimum supervision and the ability to prioritize appropriately. 
• Able to problem solve, exercise initiative and make medium to high level decisions.
• Thorough understanding of current federal, state and local