Compliance Coordinator (Managed Health Care)

Well-established managed health care/MSO management company located in the Inland Empire in Ontario seeking experienced Compliance Coordinator.  Excellent salary and benefit package.  Send resume and salary history.

 

Summary of Duties:

Primary responsibility is the overall production and maintenance of Commercial, Senior and Medi-Cal pre-service denial correspondence processing, compliance and reporting.  Responsible for auditing letters and assuring reporting to the Health Plans on all service denials.  Secondary responsibility is the assistance in QA function and programs.

 

Duties and Responsibilities:

1.  Responsible for overall functions of Pre-Service communications (denial letters).

2.  Responsible for insertion and medical language of pre-service denial letters, assure accuracy.

3.  Responsible for identification, tracking analysis and follow-up of issues for any audits and other

projects as assigned.  Assist in all othe QM audit requirements.

4.  File, track and assist in reporting monthly denial letters.

5.  Assist in accumulation of all pertinent documentation as requested by HMOs and other regulatory

   agencies as well as appropriate physicians, Medical Directors and Committees.

6.  Maintain audit and study program as per HMO and IPA Quality Management Committee

recommendations or mandates.

7.  Assure acceptable compliance with HMO and NCQA guidelines for denials.

8.  Assist IPA/Group in a proactive advisory capacity with regard to any issues identified as part of denial.

9.  Provide direct support for any audit process or follow up audit as requested.

10. Assist in preparation of IPA/Group and HMO reports regarding QM and UM activity for assigned areas.

11. Assist with collection and reporting of data and IPA specific reports.  Assure accuracy and timeliness.

  Present recommendations for actions towards continiuous improvement.

12. Maintain integrity of QM reports in a confidential manner.

13. Other duties as assigned.

 

Job Requirements:

1.  Two to three years experience in medical records auditing or quality management.

2.  Excellent verbal and written communication skills.

3.  Computer literate in work processing and spreadsheet software.

4.  Must have own transportation to go to offices and meetings.

 

www.promedhealth.com