Specialist, Clinical Operations
4 weeks ago
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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