Utilization Management Compliance Specialist

Job Description

JOB SUMMARY : Support the Compliance Department for Imperial Health Plan of California, Inc. / Imperial Health Holdings Medical Group. May support the NCQA Accreditation Program and oversight processes, CMS compliance, medicare part D& C audits and accreditation best practices and ongoing training activities.

ESSENTIAL JOB FUNCTIONS :

• Serve as the UM Compliance Specialist with Delegated Health Plan contacts for reporting deliverables. Track due dates and deliverables.
• Assist UM Lead Compliance Specialist with development of policies and procedures, program plans, and work plans for IHP / IHHMG.
• Assist in the organization of internal and external audits, compile requested documents for UM IHP / IHHMG regulatory audits, manage audit repositories and maintain master audit dashboard. Track due dates and deliverables.
• Schedule meetings for UM projects and / or regulatory audits.
• Assist in developing presentations / reports for UM.
• Acts as a resource to staff, providers and / or members for UM program information.
• Adheres to payroll policies and properly uses a timekeeping system with minimal manual changes.
• Maintains regular and consistent attendance.
• Adheres to Compliance Plan and HIPAA regulations.
• Other duties as assigned to support regulatory compliance.

MARGINAL JOB FUNCTIONS :

Takes on special projects as needed and requested.

Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS :

Continuous Learning :

Attends staff meetings as required.

Attends appropriate training, seminars and workshops as required.

Customer Focus :

Maintains client / customer confidentiality and privacy in accordance with HIPPA regulations and IMAS’s Standards of Conduct.

Fosters appropriate communication and relations with Supervisor, co-workers, and other staff.

Quality / Process Improvement / Safety

Reports issues of security, health and / or safety to appropriate supervisor as soon as practicable.

Supports and demonstrates safety throughout all duties performed.

Follows established policies and procedures and understands and complies with all regulators standards set forth by governing entities.

POSITION REQUIREMENTS :

Regulatory compliance

CMS

NCQA

Claims

EDUCATION / EXPERIENCE :

High school graduate or equivalent.

Bachelor’s Degree or equivalent combination of education and technical experience can substitute in lieu of degree.