Specialist, Clinical Operations

2 weeks ago


Los Angeles, United States MedPOINT Management Full time
Job DescriptionJob Description

Under the direction of the Supervisor, Clinical Operations (COPS), the Specialist, COPS primary responsibility is to support a strategic approach to the development of actionable recommendations that improve the quality, access, and sustainability of MedPOINT’s clients’ network.

 

Duties and Responsibilities

· Member of MPM’s COPS committee, with the goal of identifying claims & UM initiatives to drive cost efficiency and quality improvement for MPM Clients

· Identify key utilization areas for analytical focus, especially those with potential opportunity and risk

· Utilize analytical tools to examine provider behavior & practices to optimize operational efficiency

· Support the development and communication of strategic recommendations based on analyses to MPM Executives during COPS committees

· Lead efforts, both internally and externally, to operationalize strategic recommendations pertaining to MPM activities and also inform and drive change with external vendors, providers, and stakeholders

· Advance COPS initiatives with other departments, including Utilization Management, Claims, Compliance, and Finance

· Develop and lead efforts around workflows between UM and Claims departments

· Research and build the knowledge base for COPS and SOPI initiatives by attending conferences and pursuing self-study in areas regarding billing practices, provider behavior and operational improvements that could benefit COPS Committee and MPM operations

· Mitigate financial impact and utilization via ad hoc clinical review with other departments and lead & advise other departments in their continuous improvement efforts when pertaining to clinical review

· Build and maintain relationships with UM and Claims Leadership to be a key advisor to their departments on behalf of SOPI

· Provide clinical review and identify potential fraud, waste, and abuse practices

 

Minimum Job Requirements

· Clinical background with intimate knowledge of injectables, coding practices, and normal billing procedures

· Familiarity with current managed care regulatory processes

· Intermediate proficiency with Microsoft Office Excel

· Familiarity with EncoderPro and Virtual Examiner

 

Skill and Abilities

· Capable of completing complex longitudinal analyses

· Positive attitude and flexibility, a must

· Ability to deliver on departmental and company goals

· Ability to work effectively with all levels of the organization and stakeholders

· Ability to learn about regulatory requirements and provider contracting



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