Manager, Clinical Compliance, RN

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🔥 8 minutes ago

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $85k - $91k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🚔 Compliance

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Guide Healthcare

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2018

⚕️ Healthcare Insurance

🏥 Healthcare

🎯 Recruiter

Healthcare Insurance • Healthcare • Recruitment

Guide Healthcare is leading a movement where creativity delivers positive change in the healthcare sector. The company specializes in allied health service provision and healthcare recruitment, focusing on the support and treatment of older adults. With a commitment to adding value to their clients, partners, and teams, Guide Healthcare aims to do things differently in the industry.

📋 Description

• Lead a team of independent Clinical Compliance Auditors and Specialists • Supervise and direct day-to-day clinical compliance operations • Serve as the clinical services liaison to senior management and company leaders • Assist with developing coordinated companywide team processes • Coordinate orientation, training, continuing education, and performance monitoring • Promote staff professional growth and education • Oversee and assist with monthly utilization management data reports, agendas, and meeting minutes for the IPA UM Committee • Facilitate UM and PHM Plan development and adherence • Identify plan requirements and develop auditing guidelines • Serve as a secondary reviewer for denial processes and compliance audits • Review documentation submissions for timeliness • Maintain confidentiality of computer programs, medical records, and other data • Apply critical thinking and decisive judgment with minimal supervision • Ensure meeting minutes are completed, signed, and uploaded according to plan requirements • Assist with internal and external audit reviews and submissions • Complete monthly 30/30 reviews with clinical compliance auditors and specialists • Maintain a professional appearance during on-camera meetings • Perform other duties as assigned

🎯 Requirements

• Registered Nurse with an active and unrestricted license in Illinois • Three to five years of experience leading UM and PHM plan and MSA requirement changes • Experience in a managed care environment with multiple clients • Experience in the UM and PHM process and managed care • Strong organizational, written, and presentation skills • High analytical ability to define and describe complex problems • Ability to prioritize and react to rapidly changing business needs • Proficiency in medical terminology and nationally recognized medical criteria • Computer skills including Microsoft Word, Excel, Outlook, and PowerPoint • Claims processing experience preferred as a desired qualification • Coding certificates are a plus • Ability to conduct video calls on camera • Personal internet connection with minimum 100 Mbps download and 10 Mbps upload

🏖️ Benefits

• Fully remote work arrangement • Necessary work equipment provided at no charge to the employee • Comprehensive Medical, Dental, and Vision plans • 401(k) plan with a 3% employer match to the employee’s 6% contribution • Life and Disability insurance • Voluntary Life insurance options • Employee Assistance Program (EAP) • Paid time off plans • Paid parental leave • Resources for professional learning and development