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Director - Medical Review / Program Integrity - Senior Care Ops - Full Time

4 months ago

Toledo, United States ProMedica Full time

Position Summary:

ProMedica Home Health and Hospice has significant financial exposure for Fraud & Abuse / Program Integrity audits. The Agencies prepare the records for submission in conjunction with ProMedica revenue cycle staff. This position does review, follow-up, and works directly with CMS and it's contractors in conjunction with the Reimbursement AVP and Assistant General Counsel to resolve issues and minimize paybacks.

Accountabilities:

* All duties listed below are essential unless noted otherwise*

1.Acts as senior-level liaison and subject matter expert in matters concerning Medical Review policies, processes, and systems related to Program Integrity Audits for the ProMedica Hospice and Home Care Division of Senior Care.

2.Works in conjunction with the Legal Department and Outside Counsel under Attorney Client Privilege as needed in the execution of Program Integrity Medical Review Audits.

3.Attends operations meetings at the request of the GMs and RDOs.

4.Responsible for hiring, training, and effectiveness of Senior Care Medicare Ops Specialists.

5.Executes divisional and regional coverage plan and manages resources to assure that Program Integrity Audits and Medical Reviews are standardized at each location.

6.Responsible to prepare quarterly reporting using standardized measures of Medical Review established by the VP and AVP of the department.

7.Identify key Medical Review and Program Integrity trends in clinical operations of Agencies.

8.Consistently reviews and evaluates the quality of overall patient care documentation of ProMedica Hospice and Home Care Agencies. Recommends and performs training and education plans throughout the division.

9.Consistently reviews and evaluates the effectiveness of Medicare Operations Specialist tools used in the monitoring, tracking, reporting, documenting, and escalating of key clinical documentation issues

10. Maintains records of all engagements, and visits to the business units and/or with the business customer and reports outcomes in a standard format to the AVP. 1

1. Stays abreast of developments in Program Integrity and Medicare Conditions of Participation, directives, new focus, best practices, systems and technologies that impact Medical Review documentation and acts as a conduit for disseminating this knowledge throughout their teams and operational constituencies.

12. Performs all other duties as assigned.

::

Job Requirements

Education: Bachelor's degree in Nursing or RN with equivalent experience.

Skills: Strong background in Medical Review and Program Integrity. Excellent interpersonal, presentation, and communication skills. Proven problem-solving skills and the ability to be solution-oriented. Ability to conduct clinical training in group and individual settings. Ability to work with individuals of diverse backgrounds and operate effectively under pressure. Working knowledge of ProMedica Senior Care Hospice and Home Health Care applications and Microsoft Office software. Experience in managing, and holding staff accountable, as well as consulting at the senior manager and director levels.

Years of Experience: Minimum ten years experience

License: RN or equivalent professional license

Certification: N/A

ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org

Equal Opportunity Employer/Drug-Free Workplace

Employee Exemption Type

Exempt

Job Type

Full Time

Budgeted Hours / Pay Period

80

Shift Type

Days

Shift Hours

Weekends

On-call Requirements

Additional Schedule Details