UM Compliance Manager
Utilization Management Compliance Manager role with low cost medical coverage, generous paid time off and 403B Retirement plan with company match
- Greenwich, CT
- $100,000 - $100,000
- Managed by Jobot Pro: Donna Gawroski-Kusik
A bit about us:
A trailblazing fertility and family-building solutions medical benefits organization with over 25 years of success, has proudly supported over 500,000 families on the path to parenthood. To meet the evolving needs of today’s families, our organization is proud of our long-standing legacy in fertility and family well-being services, expanding offerings from pre-conception and fertility to parenting, healthy aging, and beyond. We have dramatically improved patient experience through a new and cutting-edge digital interface, customized to each patient’s journey, and expanded services designed to support the physical, emotional, and social health and happiness
We are the largest, most experienced fertility benefit management company in the country offering inclusive family-building solutions to employers, health plans and individual patients. From integrated fertility management, including medical treatment, pharmacy, and reproductive genetics, to surrogacy and adoption, our mission is to help build families by providing access to the best network of doctors, technology and emotional support at the lowest cost. Our programs include an integrated medical and pharmaceutical model that is unique to the industry. Its dedicated nurse care managers, all with experience in reproductive endocrinology clinics, guide employees through every step of their fertility journey, and are available 24/7.
We are the largest, most experienced fertility benefit management company in the country offering inclusive family-building solutions to employers, health plans and individual patients. From integrated fertility management, including medical treatment, pharmacy, and reproductive genetics, to surrogacy and adoption, our mission is to help build families by providing access to the best network of doctors, technology and emotional support at the lowest cost. Our programs include an integrated medical and pharmaceutical model that is unique to the industry. Its dedicated nurse care managers, all with experience in reproductive endocrinology clinics, guide employees through every step of their fertility journey, and are available 24/7.
Why join us?
- Low-Cost Health insurance thru United Healthcare
- Critical Illness coverage
- Dental Coverage thru Guardian
- Vision Coverage thru Guardian
- 4 weeks paid vacation.
- 9 company paid holidays.
- Always off on your Birthday
- 401K Retirement plan with Company match
- 500K Basic Life insurance coverage
- Short term and long-term care coverage
- Flex spending account
- Health Savings Account
Job Details
Looking to hire a Bachelor Degree prepared Healthcare Professional with minimum of 2 years of healthcare compliance experience
Minimum of 2 years of utilization management experience with working knowledge and understanding of basic utilization management and quality improvement concepts preferred and Knowledge of (NCQA), Utilization Review Accreditation Commission (URAC) and other general accreditation standards
HYBRID REMOTE work schedule: 1 day remote after 90 days probation , then 4 days in office and 1 remote day per week
The Compliance Manager is responsible for coordinating and performing all pre-delegation and annual due diligence audits and monitoring of delegated activities to ensure compliance with National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), contractual agreements, and State and Federal requirements. Oversees the licensing & credentialing function which ensures all company licensure (e.g. utilization management, third party administrator) and provider credentialing requirements are met and maintained per company Policies & Procedures, state regulatory requirements, and contracted health plan directives.
ESSENTIAL FUNCTIONS
Coordinate all facets of the URAC and NCQA accreditation/approval process including ensuring all activities, documentation and evidence necessary for the accreditation are prepared in compliance with accreditation standards
Serve as a resource for other departments for compliance with accreditation standards
Implements compliance programs, policies and procedures designed to ensure compliance with all applicable federal laws, regulations and delegation requirements
Analyzes delegation audit results and makes recommendations for improvement
Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/ or deficiencies. · Prepares audit files for submission as required
Participates in delegation audits, supplying information as needed
Performs tasks related to external audits from contracted health plans/employer groups as well as pre-delegation review with potential health plans as required
Coordinates with delegated partners to ensure adherence to all regulations, contractual agreements, NCQA, and URAC guidelines
Follows up on corrective action plans ensuring timely closure
Prepares adverse determination notices in compliance with regulatory requirements
Demonstrates proficiency in the application of health plan/employer group guidelines and nationally recognized review criteria
Demonstrates a solid understanding of utilization management
Reviews and adheres to department policies and the Utilization Management plan
Conduct standard random audits and focused audits to determine compliance to departmental standards
Supervises the licensing and credentialing function to ensure requirements are met and maintained
Minimum of 2 years of utilization management experience with working knowledge and understanding of basic utilization management and quality improvement concepts preferred and Knowledge of (NCQA), Utilization Review Accreditation Commission (URAC) and other general accreditation standards
HYBRID REMOTE work schedule: 1 day remote after 90 days probation , then 4 days in office and 1 remote day per week
The Compliance Manager is responsible for coordinating and performing all pre-delegation and annual due diligence audits and monitoring of delegated activities to ensure compliance with National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), contractual agreements, and State and Federal requirements. Oversees the licensing & credentialing function which ensures all company licensure (e.g. utilization management, third party administrator) and provider credentialing requirements are met and maintained per company Policies & Procedures, state regulatory requirements, and contracted health plan directives.
ESSENTIAL FUNCTIONS
Coordinate all facets of the URAC and NCQA accreditation/approval process including ensuring all activities, documentation and evidence necessary for the accreditation are prepared in compliance with accreditation standards
Serve as a resource for other departments for compliance with accreditation standards
Implements compliance programs, policies and procedures designed to ensure compliance with all applicable federal laws, regulations and delegation requirements
Analyzes delegation audit results and makes recommendations for improvement
Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/ or deficiencies. · Prepares audit files for submission as required
Participates in delegation audits, supplying information as needed
Performs tasks related to external audits from contracted health plans/employer groups as well as pre-delegation review with potential health plans as required
Coordinates with delegated partners to ensure adherence to all regulations, contractual agreements, NCQA, and URAC guidelines
Follows up on corrective action plans ensuring timely closure
Prepares adverse determination notices in compliance with regulatory requirements
Demonstrates proficiency in the application of health plan/employer group guidelines and nationally recognized review criteria
Demonstrates a solid understanding of utilization management
Reviews and adheres to department policies and the Utilization Management plan
Conduct standard random audits and focused audits to determine compliance to departmental standards
Supervises the licensing and credentialing function to ensure requirements are met and maintained
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Job Details
Managed by Jobot Pro
Location
Greenwich, CT
Job Type
Permanent
Compensation
$100,000 - $100,000