Utilization Management Compliance Specialist

4 weeks ago

Pasadena, United States Imperial Health Plan of California, Inc. Full time

JOB SUMMARY: Support the Utilization Management (UM )Program and required regulatory deliverables for Imperial Health Plan of California, Inc. / Imperial Health Holdings Medical Group. May support the NCQA Accreditation Program and oversight processes, accreditation best practices and on-going training activities.


ESSENTIAL JOB FUNCTIONS:

  • Serve as the UM Compliance Specialist with Delegated Health Plan contacts for reporting deliverables. Track due dates and deliverables.
  • Assist UM Lead Compliance Specialist with development of policies and procedures, program plans, and work plans for IHP/IHHMG.
  • Assist in the organization of internal and external audits, compile requested documents for UM IHP/IHHMG regulatory audits, manage audit repositories and maintain master audit dashboard. Track due dates and deliverables.
  • Schedule meetings for UM projects and/or regulatory audits.
  • Assist in developing presentations/reports for UM.
  • Acts as a resource to staff, providers and/or members for UM program information.
  • Adheres to payroll policies and properly uses a timekeeping system with minimal manual changes.
  • Maintains regular and consistent attendance.
  • Adheres to Compliance Plan and HIPAA regulations.
  • Other duties as assigned to support regulatory compliance.


MARGINAL JOB FUNCTIONS:

Takes on special projects as needed and requested.

Performs other duties as assigned.


BEHAVIORAL EXPECTATIONS:

Continuous Learning:

Attends staff meetings as required.

Attends appropriate training, seminars and workshops as required.

Customer Focus:

Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations and IMAS’s Standards of Conduct.

Fosters appropriate communication and relations with Supervisor, co-workers, and other staff.

Quality/Process Improvement/Safety

Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.

Supports and demonstrates safety throughout all duties performed.

Follows established policies and procedures and understands and complies with all regulators standards set forth by governing entities.


POSITION REQUIREMENTS:


EDUCATION/EXPERIENCE:

High school graduate or equivalent.

Bachelor’s Degree or equivalent combination of education and technical experience can substitute in lieu of degree.


SKILLS/KNOWLEDGE/ABILITY:

  • Excellent planning and organization skills to track competing internal/external priorities.
  • Willingness and ability to read, write, speak, understand English and have the communications skills necessary to provide accurate information to members and staff.
  • Willingness and ability to follow written and verbal direction in English.
  • Willingness and ability to maintain appropriate level of confidentiality and privacy.
  • Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.
  • Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.
  • Willingness and ability to make appropriate judgments, decisions and problem solving in a timely manner and within the context of the situation at hand.
  • Ability to effectively prioritize items/tasks as required.
  • Willingness and ability to take initiative and be a self-starter.
  • Willingness and ability to understand and comply with Federal, State, and local regulations.


LICENSURE/CERTIFICATE/TRAINING:

n/a

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