Note: The job is a remote job and is open to candidates in USA. Athens Administrators is hiring a Managed Care Compliance Administrator to ensure its Managed Care Unit’s processes and procedures meet company, customer, and regulatory quality expectations. The role oversees compliance and quality audits, training, data analysis, process improvement, and utilization review and nurse case management operations.
Responsibilities
- 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
Skills
- High School Diploma or equivalent (GED) required for all positions
- 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
- 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
- Excellent organizational skills and ability to multi-task
- Ability to type quickly, accurately and for prolonged periods
- Advanced proficiency in Microsoft Office Suite
- 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
- AA/AS or BA/BS preferred but not required
- Additional states preferred but not required
- RN or LVN license preferred but not required
- Ability to learn additional computer programs
Benefits
- 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
- Eligible employees may be considered annually for discretionary salary adjustments and/or incentive payments
- Remote work if technical requirements are met and the employee resides in a state Athens operates in
Company Overview