Compliance Coordinator

4 weeks 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 Coordinator 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.

  • HR Specialist

    4 weeks ago

    Plymouth, United States Daikin Applied Full time

    Make your mark at the world's largest HVAC company Daikin Applied is seeking an HR Specialist - Compliance. In this role you will assist in ensuring all phases of Human Resources compliance activities are followed. Under general supervision, you will assist in creating and editing programs, policies standards, processes, and measures related to HR...

  • Environmental Compliance Manager

    1 week ago

    Plymouth Meeting, United States OWL Services Full time

    Job DescriptionJob Description Who We AreOWL Services is the premier sales, installation, program management and service provider to retail, commercial, fleet, aviation and marine, and emergency power generation companies across the U.S. With 33 offices and distribution centers and more than 1,400 field service professionals, OWL delivers on a service...

  • Environmental Compliance Manager

    1 week ago

    Plymouth Meeting, United States OWL Services Full time

    Job DescriptionJob Description Who We AreOWL Services is the premier sales, installation, program management and service provider to retail, commercial, fleet, aviation and marine, and emergency power generation companies across the U.S. With 33 offices and distribution centers and more than 1,400 field service professionals, OWL delivers on a service...

  • Environmental Compliance Specialist

    6 days ago

    Plymouth Meeting, United States OWL Services Full time

    Job DescriptionJob Description Who We AreOWL Services is the premier sales, installation, program management and service provider to retail, commercial, fleet, aviation and marine, and emergency power generation companies across the U.S. With 33 offices and distribution centers and more than 1,400 field service professionals, OWL delivers on a service...

  • Health and Safety Coordinator

    3 weeks ago

    Plymouth, United States MOBIS NORTH AMERICA, LLC Full time

    Description Mobis North America, the 5th largest Tier 1 automotive supplier globally, is seeking a Health & Safety Coordinator for its Plymouth , MI R&D center. The coordinator will be responsible for providing employees with health & safety training, reporting any safety hazards/ violations, and making sure the work environment is up to par with health &...

  • Health and Safety Coordinator

    1 week ago

    Plymouth, United States MOBIS NORTH AMERICA, LLC Full time

    Description Mobis North America, the 5th largest Tier 1 automotive supplier globally, is seeking a Health & Safety Coordinator for its Plymouth , MI R&D center. The coordinator will be responsible for providing employees with health & safety training, reporting any safety hazards/ violations, and making sure the work environment is up to par with health &...

  • Project Coordinator

    1 month ago

    Plymouth, United States SERVPRO of Marshall, Starke, Pulaski & Fulton Counties Full time

    Servpro of Marshall, Starke, Pulaski & Fulton Co, is hiring a **Project Coordinator!** **Benefits** offers: - Training - Career progression - Professional development And more! The **Project Coordinator** will work as a liaison for the customer to identify project requirements and specifications as well as administer and organize projects and support...

  • Total Rewards Coordinator

    7 days ago

    Plymouth, United States Sartori Company Full time

    **ESSENTIAL DUTIES AND RESPONSIBILITIES **include the following. Other duties may be assigned. - Administer team member benefits programs, including health insurance, dental, vision, life insurance, disability, retirement plans, and other voluntary benefits. - Assist team members with benefits inquiries, enrollment, and changes. - Coordinate with benefit...

  • Administrative Specialist

    2 months ago

    Plymouth, United States WEALTH LOGIC INC Full time

    Job DescriptionJob DescriptionPosition Summary:Financial advisor seeking full or part-time administrative specialist and operations coordinator to aid in the operations and continued growth of a financial services practice.Responsibilities:Assist in the management of operations in tandem with leadershipAssist in the organization and creation of systems...

  • Administrative Specialist

    1 week ago

    Plymouth, United States WEALTH LOGIC INC Full time

    Job DescriptionJob DescriptionPosition Summary:Financial advisor seeking full or part-time administrative specialist and operations coordinator to aid in the operations and continued growth of a financial services practice.Responsibilities:Assist in the management of operations in tandem with leadershipAssist in the organization and creation of systems...

  • Project Administrative Coordinator

    4 weeks ago

    Plymouth, United States Abbott Laboratories Full time

    Working at AbbottAt Abbott, you can do work that matters, grow, and learn, care for yourself and family, be your true self and live a full life. You’ll also have access to:Career development with an international company where you can grow the career you dream of.Free medical coverage for employees* via the Health Investment Plan (HIP) PPOAn excellent...

  • Total Rewards Coordinator

    3 weeks ago

    Plymouth, United States Sartori Company Full time

    ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.Other duties may be assigned. Administer team member benefits programs, including health insurance, dental, vision, life insurance, disability, retirement plans, and other voluntary benefits. Assist team members with benefits inquiries, enrollment, and changes. Coordinate with benefit providers to...

  • Total Rewards Coordinator

    3 weeks ago

    Plymouth, United States Sartori Full time

    ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.Administer team member benefits programs, including health insurance, dental, vision, life insurance, disability, retirement plans, and other voluntary benefits.Assist team members with benefits inquiries, enrollment, and changes.Coordinate with benefit providers to...

  • Total Rewards Coordinator

    1 week ago

    Plymouth, United States Sartori Full time

    ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.Administer team member benefits programs, including health insurance, dental, vision, life insurance, disability, retirement plans, and other voluntary benefits.Assist team members with benefits inquiries, enrollment, and changes.Coordinate with benefit providers to...

  • Total Rewards Coordinator

    1 week ago

    Plymouth, United States Sartori Company Full time

    ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.Other duties may be assigned. Administer team member benefits programs, including health insurance, dental, vision, life insurance, disability, retirement plans, and other voluntary benefits. Assist team members with benefits inquiries, enrollment, and changes. Coordinate with benefit providers to...

  • Leave & Benefits Coordinator

    1 week ago

    Plymouth, United States Nexus Family Healing Full time

    Description Nexus Family Healing is excited to be hiring a Leave and Benefits Coordinator to our Home Office Human Resources team! Our Leave and Benefits Coordinator will facilitate and administer Nexus Family Healing's employee leave of absences (LOAs). This individual will provide intentional care and communication to employees on leave of absence, while...

  • Leave & Benefits Coordinator

    2 weeks ago

    Plymouth, United States Nexus Family Healing Full time

    Description Nexus Family Healing is excited to be hiring a Leave and Benefits Coordinator to our Home Office Human Resources team! Our Leave and Benefits Coordinator will facilitate and administer Nexus Family Healing's employee leave of absences (LOAs). This individual will provide intentional care and communication to employees on leave of absence, while...

  • Provider Coordinator

    2 weeks ago

    Plymouth, United States Allina Health Full time

    Number of Job Openings Available: 1 Date Posted: May 20, 2024 Department: 62742500 Orthopedic Surgery Shift: Day (United States of America) Shift Length: Variable shift length Hours Per Week: 30 Union Contract: Non-Union Weekend Rotation: None Job Summary: Maintains systems essential to the daily operations supporting patient care. Schedules and...

  • Provider Coordinator

    1 week ago

    Plymouth, United States Allina Health Full time

    Number of Job Openings Available: 1 Date Posted: May 20, 2024 Department: 62742500 Orthopedic Surgery Shift: Day (United States of America) Shift Length: Variable shift length Hours Per Week: 30 Union Contract: Non-Union Weekend Rotation: None Job Summary: Maintains systems essential to the daily operations supporting patient care. Schedules and...

  • Care Coordinator

    1 week ago

    Plymouth, United States i-Health Full time

    Description Be the Difference! Are you looking to take that next step in your healthcare career where you can make an impact and Be the Difference to patients, their families, and the community? Then Twin Cities Orthopedics has opportunities for you! The Care Coordinator will support the clinic and physician care team by providing administrative and...