Providence Health & Services UM Regional Compliance Manager in Mission Hills, California
Providence is calling a UM Regional Compliance Manager ( Full Time / Days ) to our Facey Utilization Management location in Mission Hills, CA.
In this position you will:
Oversees the utilization compliance in the UM Department for all Providence Medical Groups (PHN CA).
Responsible for the day to day management of compliance and reporting requirements between PHN CA Medical Groups UM Department per our Delegation Agreements with our contracted health plans.
Responsible for monitoring the accuracy of the documentation of member’s letters (extensions, denials, carve out and authorizations), issuance and timely submission.
Able to identify risk and compliance issues and implement Facey compliance with regulatory requirements.
Preparation and coordination of health plan and other regulatory audits in UM, QM and Provider Contracting.
Maintenance of UM referral tools and letter templates in Global Works Form Letters of GE Centricity MCA module.
Oversee preparation of weekly UM Committee meeting agenda and cases, logistics issues.
Prepare training material for all UM staff in order to be compliant with all regulations. Maintenanceof UM Policy and Procedures and coordinates review by UM RN Manager, Case Management Director, UM Director, Administrative Director of Managed Care and FMG UM Medical Director.
Assistance with Kronos PTO for Admin Director of Managed Care.
Develops and coordinates update to GE Centricity referral screens and/or UM processes along with FMF IT Support Desk.
Coordinates coverage of Request Specialist Manager.
Directs work of UM Trainers, UM Analyst and denial team.
Delegates work to UM Analyst and UM Executive Assistant. Acts as a resource for UM Directors, Managers and Supervisors on all compliance needs.
Required qualifications for this position include:
Extensive experience in the implementation of managed care processes in compliance with the UM regulatory requirements.
Preferably an Associate degree in a related field of Healthcare or commensurate experience in UM compliance and regulatory requirements of CMS, NCQA, DMHC, ICE, HIPPA and all HMO and PPO Health Plan regulations.
Minimum 2 years supervisory experience required.
Excellent writing skills and understanding of understanding of readability requirements for patient referral letters and communication.
Experience in compliance audits.
Experience in record management in preparation of audits.
Ability to organize, audit and prepare system based reports for audits. Knowledge of HMO processes, benefits, ICD-9/10, CPT coding, medical terminology.
Knowledge of Word, Excel, Power Point and data entry. Able to pull scheduled and ad hoc reports from GE Centricity.
Must possess excellent customer service and communication skills, be organized and a self-starter
About the organization you will serve:
Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita, San Gabriel and Simi Valleys. The group began as a single medical practice over 90 years ago.
Facey is part of Providence Health & Services, an integrated, not-for-profit 5-state network of hospitals, care centers, medical clinics, affiliated services and educational facilities spanning from California to Alaska.
We offer a full comprehensive range of benefits - see our website for details
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence Health & Services is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and services guided by a Mission of caring the Sisters of Providence began over 160 years ago. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Clinic/Ambulatory Care Nursing
Location: California-Mission Hills
Req ID: 226820