OneMain Financial Jobs

Description

The Supervisor, Health Plan Compliance Specialist is a registered nurse that is responsible for the oversight of the assigned utilization management (UM) employees and the UM compliance process, which includes, but is not limited to: reporting requirements, maintenance of policy and procedures, inter-rater reliability, template maintenance, health plan auditing and CAP submissions. The Supervisor, Health Plan Compliance will also have oversight of the organizations internal monitoring program.

Professional Duties

• Oversee the accurate and timely data collection and submission of files for internal/external compliance audits conducted by the Heritage Provider Network (HPN), Health Plans (HP) and/or regulatory agencies.
• Remain abreast of relevant reporting requirements. Collaborate with other UM department management and other key stake holders to routinely review departmental processes to ensure compliance with health plans and regulatory agencies. Suggest and implement changes as needed.
• Manage all DOHC/HPN/HP Monitoring Reports and Master Submission Grids. Review/edit reports for accuracy, analyze data, track and trend errors and make needed changes to ensure compliance.
• Oversee the Quality Monitoring Program and staff, including clinical notes and date/time change compliance and education.
• Oversee the Corrective Action Plan process. This includes, but is not limited to: creation, editing, completion and submission of CAPs. Reviews all CAPs for accuracy prior to on-time submission to health plans.
• Oversee the HPN/HP Denials Controls Auditing, editing, quarterly analysis and on-time submissions.
• Ongoing review of departmental policies and procedures and provides feedback to the Sr. Director, Prior Auth for review. Assists with the creation and/or updates of job descriptions and job aids in accordance with requirements established by HPN, health plans or regulatory agencies.
• Assist with the development of quality improvement tools to support compliance efforts of the UM and Referral Management Departments.
• Provide leadership and oversight to assigned employees. Coordinate and lead staff meetings, facilitate trainings, and ensure that projects and tasks are completed accurately and in a timely manner.
• Keep assigned employees informed of relevant compliance/regulatory requirement updates and updates to relevant policies and procedures.
• Serve as a resource to assigned staff and provide guidance on submission requirements.
• Complete the HPN Monthly Monitoring Reports, which includes review, root cause analysis, action planning Corrective Action Plan (CAP) responses and follow up items.
• Perform other duties as assigned.
• Serve as an ambassador for Desert Oasis Healthcare and Family Hospice Care at all times and positively shape the customer experience
• Do your share. Do what you say you will do and take action, follow through. Be willing to pitch in and help
• Be accountable for your work
• Be sensitive to factors that influence customers and co-workers situation including age, gender, culture, race and socioeconomic status. Be observant of others social cues (emotions) and respond appropriately
• Anticipate needs that will arise before your next meeting

Qualifications

• Associates degree in nursing. Bachelors degree in nursing, preferred.
• Current California Registered Nurse license.
• 3 years of experience working within a specialty area, such as, quality, compliance or utilization review. 2 years of experience working with health plans, HMOs and/or healthcare auditing and 1 year of supervisory experience.
• Knowledge of Crystal reporting. Intermediate - Proficient Knowledge of Microsoft Suite programs (Outlook, Word, Excel, Power Point, etc.)
• Ability to utilize computer and other office equipment.
• Ability to effectively communicate with individuals within al levels of the organization, patients, and individuals from other entities.
• Detail oriented and organization skills. Ability to reprioritize tasks in order to meet established deadlines.
• Ability to utilize critical thinking skills to problem solve. Ability to work with minimal supervision.
• At the discretion of DOHC/FHC management, this position has the potential to be a full or hybrid telecommuting position.

Physical Demands

Type Description

Sitting

Approximately 70% of day.

Standing

Approximately > 15% of day.

Walking

Approximately > 15% of day.

Lifting

0 - 20 lbs. (equipment, supplies) approximately >10% of day.

Bending

Approximately >10% of day. Kneeling <20%.