Compliance and Contracts Specialist

2 months ago

Plymouth, United States Fulcrum Health, Inc. Full time

Fulcrum Health, Inc. is a nonprofit, physical medicine benefit management organization that has delivered quality care through its network of over 4,800 credentialed physical medicine service providers for over 40 years. Our product offerings include acupuncture, chiropractic, massage therapy, physical, speech and occupational therapy services, serving over 2 million health plan members. Fulcrum continues to offer innovative and inspiring ways to leverage physical medicine that help lower health care costs, achieve better outcomes, and increase patient satisfaction.


The Fulcrum Health, Inc. (Fulcrum) Compliance and Contracts Specialist will assist and support the Compliance Officer in ensuring the organization has an effective compliance program and will assist the General Counsel with licensing and contract management. This position will have responsibility for some traditional compliance functions, the handling of complaints, appeals and grievances (CAG), and support for the legal department in licensing and contract management.

As part of the compliance function, this position will assist in investigation of compliance issues such as fraud/waste/abuse (FWA) cases. Responsibilities include coordinating research pertaining to the identified issue through analysis of internal data metrics, outreach to internal stakeholders/business units, communication, and requests for information to network providers and appropriate and timely resolution in accordance with contractual turnaround times.

Additionally, this position will support the Compliance Officer in the development of department policy, processes, procedures, training programs and the day-to-day operations of the Compliance department. Responsibilities will include conducting routine audits designed to test and confirm compliance with applicable state and federal laws and regulations, contractual agreements, NCQA accreditation(s), as well as internal policies and procedures.



ESSENTIAL FUNCTIONS:

Conduct Ongoing Monitoring and General Compliance Support

  • Support compliance and fraud, waste abuse investigations, internal audit and monitoring activities and other compliance initiatives through data analysis, coordination of file reviews, provider outreach, etc.
  • Establish positive working relationships with Fulcrum stakeholders to provide input on risks and controls and ensure a sustained understanding of compliance requirements while maintaining independence and objectivity.

Complaints, Appeals and Grievances

  • Analyze, answer, resolve, and document incoming telephone calls from members, providers, internal departments, and external customers and regulators.
  • Consistently monitor and research incoming appeals and grievances requests and inquiries; including potential expedites, from mail, voicemail, fax, and email.
  • Contact members, providers, health plan customers, and delegates as necessary to proactively obtain information required to complete appeals and grievances and educate on the process.
  • Ensure all appeals and grievances are entered in the system and maintain accurate documentation according to State, Federal or Commercial regulatory guidelines.
  • Manage a caseload of appeals and grievances along with managing all other intake and resolution duties as stated above.

Contract Management

  • Manage tracking, storage and change management of vendor and client contracts.
  • Review, recommend and implement (after approval) improvements to contract management process.
  • Manage new vendor contract process to ensure all necessary compliance checks are completed and contract is duly executed and properly tracked.

Licensure Filings and Maintenance

  • Manage Company license filings in various states and handle license renewals as necessary.
  • Track and report licensing requirements and status.

Participate in External Audits, e.g. Health Plan Customers, CMS, DHS, NCQA, etc.

  • Conduct initial file review for compliance with customer instructions and audit elements, i.e. NCQA, state and federal requirements.
  • Help coordinate implementation and monitoring of activity, including any necessary corrective action plans, to reduce exposure and correct defective policies.

Other projects or duties as assigned.



REQUIRED QUALIFICATIONS: (Minimum qualifications needed for this position)

  • Associate's degree or 5 years of related work experience in lieu of a degree
  • 3 or more years of experience in Compliance, Audit, CAG, SIU, provider services or member services department within a health care organization
  • Well-developed organizational skills with the ability to prioritize multiple time-sensitive assignments.
  • Understanding of business processes and audit functions.
  • Strong skills using Microsoft Office (primarily Word, Excel, Power Point and Outlook) and a willingness to learn other software applications.
  • Ability to work independently and contribute to a positive team atmosphere.


PREFERRED QUALIFICATIONS:

  • Experience answering benefit and claim questions. Claims adjudication process experience.
  • Managed care and/or HealthPlan experience.
  • 4 or more years of experience addressing member complaints, internal concerns, and/or incident reports.

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