Clinical Compliance Specialist – Audits & Quality

The Health Plan Of West Virginia Inc; Wheeling (WV); Presencial; USD 65.000 - 80.000; Jornada completa

Descripción de la vacante

The Health Plan Of West Virginia Inc is seeking a Clinical Compliance Coordinator to assist in overseeing CMS, NCQA, ERISA, and regulatory compliance. This full-time clerical role is based in Wheeling, WV and focuses on improving accuracy, quality, and reporting of clinical processes.

Responsibilities include audits, interrater reviews, staff education, and KPI reporting using CMS OMT and SharePoint. Strong analytical, organizational, and communication skills are required.

Formación

• Bachelor's degree in a healthcare related field.
• At least 1 year of managed care experience.
• Preferred certification in managed care or case management or pursuit within 2 years.
• Excellent oral, written, telephonic and interpersonal skills.
• Awareness of CMS, NCQA, ERISA, Department of Labor regulations.
• Detail oriented with strong time management and organization.
• Ability to work independently and in teams.
• Proficient keyboarding and computer literacy.

Responsabilidades

• Displays comprehensive understanding of all related Utilization Management (UM) processes and programs.
• Assists the Supervisor of Government Productions with troubleshooting daily prior-authorization concerns.
• Assists with remediation plans regarding referral process, as needed. CMS & BMS guidelines.
• Promotes and supports quality effectiveness of Healthcare Services by providing Staff education (monthly staff meetings) all-inclusive to referrals and compliance related to referrals in collaboration with Directors and manager(s).
• Collaborates and shares knowledge and expertise with peers, supervisors, and other Health Plan staff.
• Assists the Manger of Clinical Compliance with reporting and audits to ensure accuracy of clinical performance against regulatory requirements.
• Performs daily, monthly, quarterly, and annual reporting of THP and delegated UM key performance indicators, as directed.
• Completes reporting in the CMS On-line Monitoring Tool (OMT) and SharePoint as assigned by the compliance department.
• Assists the Manager of Clinical Compliance with the creation and completion of the NCQA and Clinical Compliance Work Plans, which provide qualitative and quantitative analyses of Key Performance Indicators and NCQA standards.
• Identifies opportunities for improvement in systems, processes, functions, reporting, programs, procedures and makes recommendations to the Manager of Clinical Compliance.
• Serves as assigned on departmental or company committees.
• Assists in updating the Clinical Compliance Calendar.
• Prioritizes assignments appropriately and maintains flexibility as new priorities arise.

Conocimientos

Communication skills

Analytical skills

Problem-solving

Time management

Independent judgment

Teamwork

Computer literacy

Educación

Bachelor's degree in a healthcare related field

Herramientas

CMS On-line Monitoring Tool (OMT)

SharePoint

Descripción del empleo

The Health Plan Of West Virginia Inc is seeking a Clinical Compliance Coordinator to assist in overseeing CMS, NCQA, ERISA, and regulatory compliance. This full-time clerical role is based in Wheeling, WV and focuses on improving accuracy, quality, and reporting of clinical processes.

Responsibilities include audits, interrater reviews, staff education, and KPI reporting using CMS OMT and SharePoint. Strong analytical, organizational, and communication skills are required.