Overview:
Kelsey-Seybold Clinic, a Houston tradition in patient-centered care, is a multispecialty clinic with over 25 locations and comprises more than 500 physicians providing primary and specialty care in a collaborative manner.
With 55 different clinical and non-clinical specialties, you can design a career path at Kelsey-Seybold Clinic that allows you to grow your future in a completely new direction.
Kelsey-Seybold Clinic is changing the way health cares.
Responsibilities:
The Manager of Delegation Oversight is accountable for activities and personnel related to Utilization Management (UM) and Claims auditors to manage both delegated commercial and Medicare Benefit products. Manage all aspects of utilization review and claims in accordance with regulatory and accreditation requirements (TDI, CMS, etc.), documentation/policy updates and related education in coordination with the Director of Compliance. Provides direction and leadership for multiple projects, services and associated deliverables of significant complexity and/or impact related to monitoring performance and reporting compliance issues to maintain UM and Claims delegation. Primary contact for UM and Claims delegation audit requests, working directly with external auditors and carrier leadership. Act as a liaison and resource to the carriers regarding contract and regulatory requirements, as well as the communication of new or revised requirements. Also acts as chair for Delegation Oversight Committee and participates in UM Committee.
Qualifications:
Manager, Delegation Oversigh
t
Location: Pearland Administrative Office
Department: Delegation Oversight
Job Type: Full Time
EDUCATION REQUIREMENTS & EXPERIENCE REQUIREMENTS
(A = basics; B = preferred)
Education
A.
Bachelor’s degree or equivalent experience.
B.
Bachelor of Science in Nursing, Healthcare Administration or a related field
Experience
5 years supervisory or management experience
5-7 years of health plan, managed care organization, and/ or Utilization Management experience
3-5 years of auditing/monitoring experience and/or oversight of auditing/monitoring processes.
B.
Managed Care, quality, auditing or compliance experience
Experience reviewing/interpreting Medicare and applicable State regulatory requirements, including the ability to easily access and interpret these guidelines.
3 – 5 years of project management experience
Nursing experience in support of Utilization Review or Claims processing
Special Skills
A.
Excellent verbal and communication skills, and organizational skills.
Proficiency in MS office products with intermediate experience in Word, Outlook and Excel required
Applied knowledge and understanding of medical policy, benefit design, and interpretation, and problem resolution.
B.
Epic Experience
Knowledge of ICD-10 Coding methodologies, Managed Care payment methodologies, and process improvement methodology
Knowledge of CMS Guidelines, MCG, InterQual or other medically appropriate clinical guidelines
Knowledge of Utilization Management standards with NCQA and URAC
Other
A.
Consistent and prompt attendance at employer worksite is an essential job requirement.
B.
Computer literate.
Ability to work from designated office for collaborative / interactive fulfilment of duties; ability to concentrate in an open-office cubicle environment; interact with other staff members and / or outside associates; perform telephone and / or computer work for extended periods of time; operate office equipment such as a computer, telephone, and copy / scan / fax machine; actively participate in department meetings via phone, computer or in person
WORKING ENVIRONMENT
Office