DaVita Manager, Claims Quality Compliance in EL SEGUNDO, California

Manager, Claims Quality Compliance

Description

DaVita Medical Group manages and operates medical groups and affiliated physician networks in California, Nevada, New Mexico, Florida, Colorado and Washington in its pursuit to deliver excellent-quality health care in a dignified and compassionate manner. As of June 30, 2016 DaVita Medical Group (formerly HealthCare Partners) provided integrated care management for approximately 760,000 patients. DaVita Medical Group’s leadership development initiatives and social responsibility efforts have been recognized by Fortune, Modern Healthcare, Newsweek and WorldBlu.

We are committed to bringing the benefits of coordinated care to our patients and to taking a leading role in the transformation of the national healthcare delivery system to assure quality, access, and affordable care for all.

If you're looking to make a difference with a large, financially stable, well-recognized medical group, DaVita Medical Group may be the employer for you.

Overview:

Oversees the coordination, document preparations ofthe full service health plans, CMS & DMHC audits; Oversees the intakeof the correspondence from various health plans; Assumes the lead role in thedevelopment, implementation, and adherence to compliance related standards asmandated by legislation, health plan directives, or company policy andprocedures; Performs initial and periodic assessments to determine the need fornew or modified oversight of compliance procedures; Assists with the analysisand interpretation of regulatory compliance requirements; Assists in the monitoringof compliance systems or protocols to ensure their effectiveness; Responsiblefor managing the Delegation Oversight team including the monthly and yearlyperformance of the team; Ensures compliance with company policies andapplicable federal, state and local laws; Implement, issue or respond tocorrective actions as needed;

Essential Functions:

  • Oversees the intake of the correspondence from various health plans.

  • Participates in the development, review, implementation, and ongoing monitoring of Delegation Oversight

  • Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.

  • Works closely with the Claims management team, regional management team and other departments to resolve specific claims issues and ensures compliance with all health plan requirements and industry regulations.

  • Attends meetings to provide input (i.e. reports trends and assesses the root of the problem), obtains information and disseminates results of these meetings appropriately.

  • Assumes the lead role in the development, implementation, and adherence to compliance related standards as mandated by legislation, health plan directives, or company policy and procedures.

  • Assists with the analysis and interpretation of regulatory compliance requirements.

  • Performs initial and periodic assessments to determine the need for new or modified oversight of compliance procedures

  • Assists in the monitoring of compliance systems or protocols to ensure their effectiveness

  • Ensures Claims policy and procedures adhere to mandated state and federal legislation and health plan directives.

  • Keeps abreast of all regulatory and health plan requirements and claims processing regulations.

  • Implements, issues or responds to corrective actions as needed.

  • Applies appropriate reference tools (e.g. Prospective Review List, Preferred Provider List, CPT and ICD-9 coding books, HCP and IMCS policies and procedures manual).

  • Recommends and implements changes to internal company processes as needed.

  • Participates in the development and implementation of strategic workgroups (internal and external).

  • Participates in the preparation process for the annual budget and monitoring of monthly budget year to date.

  • Provides direction, guidance, and training to department supervisors and staff.

  • Responsible for managing the Delegation Oversight team including the monthly and yearly performance of the team

  • Assists in the development of departmental and individual goals.

  • Ensures appropriate management of department staff including timely completion of performance appraisals and corrective counseling when necessary.

  • Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.

  • Ensures compliance with company policies and applicable federal, state and local laws

  • Performs additional duties as assigned.

Qualifications

EDUCATION:

  • One or two years of post-high school education or a degree from a two-year college.

EXPERIENCE:

Minimum:

  • Over 5 years and up to and including 10 years of experience.

Preferred:

  • Over 5 years of benefits, claims and referral experience in a healthcare setting.

KNOWLEDGE, SKILLS, ABILITIES:

  • Computer literate.

  • Proficient in Microsoft Office applications.

  • Advanced knowledge of medical terminology, ICD-9 and CPT coding.

  • Proven problem-solving and decision-making skills.

  • Strong leadership skills.

  • Excellent verbal and written communication skills.

  • Excellent organizational and time-management skills.

  • Detail-oriented

  • Excellent customer service skills.

  • Ability to work independently.

  • Valid California driver’s license.

Primary Location CA-EL SEGUNDO - 90245

Req ID: 303437