Managed Care Compliance Administrator

Athens Administrators, Inc.; Nevada; A distancia; USD 90.000 - 120.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical

Vision

Dental

Life and AD&D

Long Term Care

Critical Care

Accidental

Hospital Indemnity

HSA & FSA options

401k (and Roth)

Company‑Paid STD & LTD

Descripción de la vacante

Athens Administrators, a nationwide family‑owned claims administrator, seeks a full‑time Managed Care Compliance Administrator to join the Managed Care team. This role can be remote if technical requirements are met and the employee resides in CA, AZ, CO, ID, NV, OK, TX, or OR.

Office hours are 7:30–5:30 local time, with a 9:00–17:00 PST schedule. The successful candidate will oversee audits, training, data analysis, and process improvement to ensure regulatory and quality compliance, while

Formación

• High School Diploma or GED or equivalent required.
• AA/AS or BA/BS preferred but not required.
• 5 years of utilization review, QA, case management or workers’ comp experience required.
• Fully versed in CA, AZ and TX workers’ comp laws; other states a plus.
• RN or LVN license preferred but not required.

Responsabilidades

• Develop and maintain UR plan and best practices.
• Monitor day‑to‑day utilization review and nurse case management operations.
• Create department policies and workflows compliant with DWC standards.
• Oversee workflow of managed care services and cost containment strategies.
• Provide support to UR coordinators and NCMs for efficient operation.
• Train, supervise, and evaluate UR and NCM staff; verify licenses and CEUs.

Conocimientos

Utilization review

Quality assurance

Case management

Professional communication

Training and supervision

Analytical skills

Critical thinking

Data analysis

Interpersonal skills

Educación

High School Diploma or GED

AA/AS or BA/BS preferred

Descripción del empleo

Position:Managed Care Compliance Administrator

Location: California, Texas, Arizona, or Nevada

Remote Status: Remote

Job Id:1654

# of Openings:1

ATHENS POSITION DETAILS

Position Title:

Managed Care Compliance Administrator

Department:

Managed Care – Orange, CA

Reports To:

Reports To: Managed Care Manager

FLSA Status:

Exempt

Job Grade:

13

ATHENS ADMINISTRATORS

Explore the Athens Administrators difference: We have been dynamic, innovative leaders in claims administration since our founding in 1976. We foster an environment where employees not only thrive but consistently recognize Athens as a “Best Place to Work.” Immerse yourself in our engaging, supportive, and inclusive culture, offering opportunities for continuous professional growth. Join our nationwide family‑owned company in Workers' Compensation, Property & Casualty, Program Business, and Managed Care. Embrace a change and come make an impact with the Athens Administrators family today!

POSITION SUMMARY

Athens Administrators has an immediate need for a full‑time Managed Care Compliance Administrator to support our Athens Managed Care department and can be located remotely if technical requirements are met and the employee resides in CA, AZ, CO, ID, NV, OK, TX, or OR. Athens offices are open for business Monday‑Friday from 7:30 a.m. to 5:30 p.m. local time. The schedule for this position is 9am to 5pm PST regardless of time zone.

The Compliance Administrator ensures that the processes and procedures of the Managed Care Unit meet the overall quality expectations of the company, customers, and regulations. This includes quality and compliance audits, training, data analysis, and process improvement.

Our new hire should have the skills, ability, and judgment to perform the following essential job duties and responsibilities with or without reasonable accommodation. Additional duties may be assigned:

• Develop and maintain Athens UR plan and best practices.
• Monitor and evaluate all aspects of the day‑to‑day utilization review and nurse case management operations
• Create department best practices, policy and procedure and workflows that are in compliance with the DWC standards
• Responsible for overall workflow of managed care services, incorporating the strategies of cost containment, appropriate utilization of services and case management in a cooperative effort with external and internal parties
• Provide technical support to Utilization Review (UR) coordinators and Nurse Case Managers (NCM) to ensure the efficient operation and profitability of department
• Responsible for the ongoing training, supervision and evaluation of professional staff performing Utilization Review (UR) and Nurse Case Management (NCM) services, verifying nursing licenses, ensuring that CEU’s are obtained, assist clinical staff with review process, create and maintain training materials
• Develop and recommend corrective and preventative actions in collaboration with the Quality Assurance Specialist
• Coordinate audits as needed
• Work closely with the Managed Care Supervisor to develop and monitor key performance indicators
• Appropriately communicate organization information through department meetings, one‑on‑one meetings, appropriate email, and regular interpersonal communication
• Responsible for Athens Managed Care URAC accreditation
• Support Managed Care Supervisor and Managed Care Director in identifying and developing internal opportunities to work with Worker’s Compensation Claims staff to educate them on AMC services and drive Managed Care preferred vendor referrals
• Responsible for creating all necessary forms, letters and templates to be contained within the system
• Identify unique and efficient approaches to conducting the core processes of AMC that will produce outcomes that are superior within the industry

The requirements listed below are representative of the knowledge, skill, and/or ability required. While it does not encompass all job requirements, it is meant to give you a solid understanding of expectations.

• High School Diploma or equivalent (GED) required for all positions
  • AA/AS or BA/BS preferred but not required
• 5 years of utilization review, quality assurance, case management or workers’ compensation experience required
• Must be fully versed in CA, AZ and TX state workers’ compensation laws and practices. Additional states preferred but not required
• RN or LVN license preferred but not required
• Effectively influence people to achieve unit and organizational objectives
• Excellent interpersonal and communication (written and oral) skills, including the ability to convey technical details
• Ability to develop and maintain effective relationships with co‑workers, vendors, management and other key stakeholders to achieve organizational goals
• Self‑directed and able to independently evaluate, determine priorities and manage projects with a high level of attention to detail
• Ability to meet multiple demands and deadlines
• Exercise independent judgment and analytic ability in solving complex and sensitive problems.
• Ability to leverage technology for self and staff to improve efficiency within department
• Mathematical calculating and analytical skills
• Ability to type quickly, accurately and for prolonged periods
• Ability to learn additional computer programs
• Reasoning ability, including problem‑solving and analytical skills, i.e., proven ability to research and analyze facts, identify issues and make appropriate recommendations and solutions for resolution
• Ability to be trustworthy, dependable, and team‑oriented for fellow employees and the organization
• Seeks to include innovative strategies and methods to provide a high level of commitment to service and results
• Ability to demonstrate care and concern for fellow team members and clients in a professional and friendly manner
• Acts with integrity in difficult or challenging situations and is a trustworthy, dependable contributor.
• Athens’ operations involve handling confidential, proprietary, and highly sensitive information, such as health records, client financials, and other personal data. Therefore, maintaining honesty and integrity is essential for all roles within the company.
• Valid driver’s license and availability for travel including overnight

This description portrays in general terms the type and levels of work performed and is not intended to be all‑inclusive or represent specific duties of any one incumbent. The knowledge, skills, and abilities may be acquired through a combination of formal schooling, self‑education, prior experience, or on‑the‑job training.

Athens Administrators is an Equal Opportunity/ Aff…

THANK YOU!

We look forward to reviewing your information. We understand that applying for jobs may not be the most enjoyable task, so we genuinely appreciate the time you’ve dedicated. Don’t forget to check out our website at www.athensadmin.com as well as our LinkedIn , Glassdoor , and Facebook pages!

Athens Administrators is dedicated to fair and equitable compensation for our employees that is both competitive and reflective of the market. The estimated rate of pay can vary depending on skills, knowledge, abilities, location, labor market trends, experience, education including applicable licenses & certifications, etc. Our ranges may be modified at any time. In addition, eligible employees may be considered annually for discretionary salary adjustments and/or incentive payments.

• Medical
• Vision
• Dental
• Life and AD&D
• Long Term Care
• Critical Care
• Accidental
• Hospital Indemnity
• HSA & FSA options
• 401k (and Roth)
• Company‑Paid STD & LTD

Further information about our comprehensive benefits package may be found on our website at https://www.athensadmin.com/careers/why-work-here