Job Description:
SCOPE OF POSITION:
Responsible for the efficient and effective development, production, and management of all aspects of AFMC’s clinical case review in Medicare, Medicaid, and private review contracts as well as referrals by outside agencies. Develop relationships and promotes mutually beneficial partnerships with clients, key stakeholders, constituents, provider groups, other healthcare organizations and the community at large. Market the programs and services of AFMC to existing and new stakeholders. Support the organization’s mission, vision, and values by exhibiting the following behaviors: Honesty, Excellence Accountability, Respect and Teamwork.
ESSENTIAL JOB FUNCTIONS:
- Responsible for contract deliverables for multiple clients and spanning a variety of clinical services programs, products, and services. Facilitate mission goals across teams at the organizational level.
- Communicate effectively with internal and external clients. Upon request, verbally informs patients, facility personnel, the attending physician and other ordering providers, and health professionals of specific utilization management requirements and procedures
- Meet regularly with the COO and other senior management to stay informed, to offer direction and support for inter-departmental projects and to confer on organizational goals, objectives, and policies.
- Develop relationships and promotes mutually beneficial partnerships with clients, key stakeholders, constituents, legislators, other healthcare organizations and the community at large.
- Function as a resource for clinical and non-clinical staff by providing oversight and follow-up for clinical related questions or issues.
- Perform HCPCS/CPT code conversions.
- Confer with the COO and other senior management to identify and develop new opportunities for expanding the business. Monitor current contracts and clients to establish “new business” goals and revenue growth opportunities.
- Work closely with corporate Medical Director in recruiting, training, and retaining Physician Advisors for case review.
- Design and conduct workshops and/or seminars as needed.
- Contribute and edit scientific articles, which will be submitted to medical, epidemiology or statistical journals.
- Select, direct, coach and evaluate assigned staff. Develop standards of staff performance and set annual performance objectives. Ensure the quality and accuracy of employees’ work product and that staff meet performance goals within designated time frame.
- Maintain current knowledge of corporate contracts with emphasis on opportunities for new business.
- Attend Board Meetings upon CEO request. Work with board and board committees on case review issues.
- Prepare and submit monthly, quarterly, and annual reports to clients and CEO.
- Prepare annual departmental budget. Analyze and control expenditures of department to conform to budgetary requirements.
- Adhere to format, content, and style guidelines, considering usability and ensuring accuracy, consistency and quality.
- Follow AFMC, state and federal protocols regarding data confidentiality/security and HIPAA compliance.
- Meet regularly with assigned staff to communicate pertinent information, needs and requests to other team members as appropriate.
- Meet with other Quality Management Committee members to stay informed, to offer direction and support for quality management. Five percent of your time is allocated to the Quality Management Committee.
- Train assigned staff on job specific regulations and contract requirements.
- Additional duties as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES:
- Intermediate skill level with MS Office (Word, Excel, Outlook, PowerPoint).
- Type 40 wpm.
- Exceptional skills in business English and spelling are required.
- Good command of the English language and knowledge of punctuation, grammar, and spelling are required.
- Knowledge of regulations and contract requirements pertaining to the assigned area of responsibility.
- Ability to lead and participate in multi-disciplinary team projects involving professional personnel from several fields.
- Ability to manage and direct the work of outside consultants, outsourced services and other external entities.
- Well-developed planning, marketing, organizational development, and business skills.
- Ability to build and manage partnerships and relationships with a variety of stakeholders required.
- Strong detail orientation, organizational and project management skills evidencing an ability to respond to multiple projects simultaneously with appropriate sensitivity and tact including the ability to manage through conflict.
- Ability to negotiate both financially and conceptually and reach mutually agreeable solutions.
- Advanced financial analysis skills.
- Ability to maintain confidentiality.
- Coaching skills.
- Creativity.
- Customer service.
- Ability to delegate as required.
- Ability to meet deadlines.
- Flexibility.
- Ability to work collaboratively and independently to achieve stated goals.
- Initiative.
- Ability to relate professionally and positively with staff, business partners, customers, constituents, recipients, and the public.
- Knowledge of ICD 9/ICD 10 Coding.
- Knowledge of HIT/HER.
- Medical terminology.
- Leadership skills.
- Ability to prioritize.
- Problem solving skills.
- Professionalism.
- Strong public speaking skills.
- Ability to travel, including overnight travel.
- Time management skills.
Physical and Sensory Requirements (With or Without the Aid of Mechanical Devices):
Mobility, reaching, bending, lifting, grasping, ability to read and write ability to communicate with personnel and ability to remain calm under stress. Must be capable of performing the essential job functions of this job, with or without reasonable accommodations.
EDUCATION:
Required: Bachelor’s degree in nursing and currently licensed as a Registered Nurse in the state of Arkansas, without restrictions.
Desirable: Master’s degree in nursing, public health, healthcare administration, business administration or statistics
EXPERIENCE:
Required: Six (6) years’ experience in nursing, Four (4) years leadership experience. Five (5) years utilization review, quality assurance, coding or RHIT/RHIA hospital experience, experience and knowledge of Medicare, Medicaid, and other major managed healthcare programs
Desirable: Experience in a QIO, non-profit and/or professional services healthcare setting
INTERNET REQUIREMENTS:
Reliable, high-speed wireless internet service (Wi-Fi)