Reference #: GUIDUS33338EXTERNALENUS10503SUMMARY STATEMENTThis position is responsible for supervising and coordinating the varied and highly visible activities of operational departments that perform clinical reviews. This includes direct supervision of support staff and clinical professional staff in conducting medical review, provider education and appropriate referrals to the Unified Program Integrity Contractor (UPIC) for potential fraud and abuse related to the Medicare Program as well as various other external entities (e.g. Quality Improvement Organization (QIC), Recovery Auditor Contractor (RAC), Centers for Medicare and Medicaid Services (CMS), etc.).

　　ESSENTIAL DUTIES & RESPONSIBILITIESTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.1) Communicate effectively with all levels of the organization and outside entities by:* Managing customer expectations (internal and external); facilitating, planning and designing training presentations, meetings, translating requirements for staff and peers, representing the company regarding clinical reviews with outside entities (e.g., Office of Inspector General (OIG), CMS, physician offices including compliance departments and corporate Chief Executive Officers (CEOs), etc.).* Preparing and reviewing written procedures, policies, reports and correspondence; collaborating and training with other departments corporate wide.* Preparing and reviewing written website materials to maximize communication with external customers.* Collaborating with other departments and other stakeholders in identifying customer needs or concerns, considering available options, comparing costs and benefits, and recommending cost-effective recommendations.2) Administering oversight activities:* Providing direct oversight and/or technical direction as necessary of both technical support staff and clinical professional staff.* Evaluating workflow of clinical workloads and adjusting when necessary. Supporting changes or improvements to base/non-base systems applications.* Developing and implementation of performance expectations.* Understanding and supporting operational policies and procedures.* Actively identifying, developing and deploying process improvement activities.* Identifying opportunities, through the use of Medicare policies and procedures, processing procedures and related data processing systems, to improve department's overall performance.* Ensuring compliance with regulatory, legislative, CMS and company requirements and commitments.* Analyzing internal processes for compliance to regulatory and enterprise requirements.3) Accountable for the coordination and management of all technical support and clinical reviews and personnel and effective and efficient implementation of all clinical reviews including implementation and monitoring of the Improper Payment Reduction Strategy (IPRS), appeals, and/or prior authorization programs.* Work with managers, Contractor Medical Directors, and other departments as well as own department manager to ensure appropriate clinical review activities are being conducted.* Ensure appropriate clinical review resources are used efficiently and effectively in keeping within budget and CMS directives to conduct assigned activities, which could include educating (both written and verbal education) Medicare Part A and Part B physicians and suppliers on Medicare policies, coverage, and coding guidelines.* Monitor the outcomes and effectiveness of clinical activities.* Identify and recommend to management process improvements that will increase productivity and improve quality of outputs.* Ensure compliance with corporate standards as well as applicable CMS req irements as they relate to change requests, management controls, process quality plans, the Medical Review (MR) quality program, internal and external audits, etc.4) Assist with developing, monitoring, and implementing clinical strategies for the Prior Authorization Program and/or the Improper Payment Reduction Strategy (IPRS) and all clinical workload and reporting requirements.* Work with the appropriate data analysis team member to ensure all appropriate issues are incorporated into the clinical strategies for the Prior Authorization program and via the IPRS for MR (does not apply to Appeals).* Assist in the development of workload projections and ensure that all workload and budget targets are met.* Daily monitoring of workload projections and timeliness of clinical workloads and output.* Development of specific tools for monthly workload and timeliness verification strategies.* Assist with preparations of the reports (monthly and periodic) for submission to CMS timely and accurately.* Participate in meetings and data analysis reviews to identify MR and Prior Authorization opportunities (does not apply to Appeals).5)  Development and monitoring, in conjunction with the appropriate team, an MR Effectiveness Program. (applicable only to MR).* Participate in the review of data and findings to continually demonstrate the effectiveness of MR interventions and continually improve IPRS.* Be familiar with outcome based metrics and data interpretation.* Assist with analyzing appeals data to identify educational opportunities and coordinate findings with the Appeals Department.6) Oversee and supervise all clinical interventions to include documentation reviews, one- on-one educational contacts, and assist, as needed, in developing articles for publication.* Oversee clinical documentation reviews and when needed, coordinate and conduct meetings and educational sessions with providers.7) Coordinate and facilitate clinical interdisciplinary meetings and/or documentation to include maintaining a central file, documenting meeting notes, preparing agendas, and coordinating action items, as appropriate.* Interact with other managers and supervisors to ensure they remain apprised of all pending action items and activities pertaining to their operational areas.Performs other duties as the supervisor may, from time to time, deem necessary.

　　REQUIRED QUALIFICATIONS* High School diploma or GED* 3+ years' related work experience with a minimum of 2 years' clinical work experience and a minimum of 2+ years' direct supervisory/project management lead or other leadership experience.* Valid unrestricted Registered Nurse (RN) license

　　PREFERRED QUALIFICATIONSBachelor of Science in Nursing (BSN) and three (3) years' experience or Associates Degree and five (5) years' experience in clinical or healthcare industryClinical Inpatient Rehabilitation Facility experience and/or experience reviewing Inpatient Rehabilitation FacilitiesMaster of Science in Nursing or Master's Degree in business, healthcare administration, public health, or health-related discipline1-3 years' experience working in Medicare Program or with Medicare Regulations 3-5 years of experience working on a personal computer in Microsoft Windows or similar environmentExperience using claims processing system (e.g., MCS/FISS), etc.An understanding of statistics in order to analyze and validate various reportsCPC, CHC-H, or equivalent

　　The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for