Quality Risk Management – Director - Missoula, MT - $120,000 - $135,000

Quality Risk Management – Director

Missoula, MT

$120,000 - $135,000

Job Description

This is a full time (Exempt 1.0 Status) day shift Director position in the Quality & Risk Management department.

This is a professional leadership position assuring department performance in quality management functions, risk management functions, medical record review and abstracting functions, software implementation processes, regulatory compliance, medical staff office functions and credentialing functions.

Ensures alignment of services with our mission, vision, and core values: Champion patient care, Do the right thing, Embrace individuality, Act with kindness, and Make a difference. Everything we do is driven from and tied to these five core values.

Minimum Requirements: 

·        Education and licensure commiserate with professional field (Nursing, Therapy, Pharmacist, Dietician, Attorney).

·        Bachelor’s Degree in appropriate discipline.

·        2-5 years' experience with regulatory and accrediting agencies including CMS and Joint Commission.

·        Previous management experience and decision making.

·        Knowledgeable in computer processing, data entry and management of databases.

·        Demonstrated ability to collaborate with others and coordinate activities.

·        Demonstrated problem solving abilities.

·        Demonstrated qualities of flexibility, creativity, and accountability.

·        Proven organizational skills demonstrating ability to establish priorities and meet deadlines.

·        Excellent written and oral communication skills.

·        Demonstrated ability to work independently. 

·        Previous experience with hospital committees.

·        Must be able to successfully obtain CPPS certification within six months of hire.

·        Must have the ability to respond to professionally sensitive issues.

Preferred/Desired:

·        Appropriate Master’s Degree related to discipline and/or MBA/Leadership Acute care nursing experience and familiarity with quality and risk management functions preferred.

·        Prefer knowledge in statistical methods and analysis. Prefer Medical Staff Office experience.

Director of Emergency Department - USA, Ottumwa IA - $95,000 - $115,000

Director of Emergency Department

USA, Ottumwa IA

$95,000 - $115,000

Job Description

GENERAL SUMMARY OF DUTIES – The Director of Emergency Services provides clinical and administrative leadership and expertise in the field of emergency medicine, and is responsible for the implementation of the vision, mission, plans, and standards of the organization and nursing services. 

SUPERVISOR – Chief Nursing Officer

SUPERVISES – Emergency Department and Ottumwa Regional Mobile Intensive Care Services (ORMICS) Staff

DUTIES INCLUDE BUT ARE NOT LIMITED TO

·       Participates, and facilitates staff participation, in nursing and organizational policy formulation and decision-making.

·       Accepts organizational accountability for services provided to recipients.

·       Evaluates the quality and appropriateness of care.

·       Provides guidance for and supervision of personnel accountable to the Director of Emergency Services including evaluation of performance.

·       Coordinates nursing services with the services of other health care disciplines.

·       Participates in the recruitment, selection, and retention of personnel.

·       Assumes accountability for staffing and scheduling personnel. 

·       Assures appropriate orientation, education, credentialing, and continuing professional development for personnel.

·       Develops and monitors the budget for defined areas.

·       Participates and involves nursing staff in evaluative research activities.

·       Fosters a climate conducive to educational experiences for nursing and other students.

·       Maintains oversight of the hospital trauma program and ensures that the facility is meeting all state requirements for trauma designation.

·       Assures appropriate level of understanding, awareness and compliance with all applicable Joint Commission, CMS, state and local agency laws, internal/external regulations, guidelines, policies, procedures and professional standards.

·       Other duties as assigned.

KNOWLEDGE, SKILLS & ABILITIES  

·       Effectively communicates with patients, visitors, associates and others.

·       Ability to take quick action to resolve customer complaints.

·       Ability to maintain accurate records and reports questionable practices.

·       Knowledge of current practices in emergency nursing and pre-hospital care

·        Strong interpersonal and communication skills, including ability to motivate personnel.

·        Clear, concise and persuasive writing and presentation skills.

·        Strong orientation to deadline and detail.

·        Frequent public speaking/training expected.

·        Word Processing PC Skills, knowledge of PowerPoint and Excel desirable.

·        Decisive and capable of exercising good judgment under pressure.

·        Ability to manage a diverse and demanding workload. 

·       Ability to collect, analyze and present data.

EDUCATION

·       Baccalaureate degree in nursing or related field, or AD in nursing with demonstrated equivalent competencies and enrollment in baccalaureate program.

·       Master's degree preferred.

EXPERIENCE 

·       3-5 years’ experience in related clinical practice with minimum of 1-2 years in clinical leadership role.

CERTIFICATE/LICENSE

·       Current RN license in the state of Iowa.

·       Current certification in BLS.

·       Must obtain ACLS and PALS certifications within 6 months of hire.

·       Must obtain TNCC certification within one year of hire.

Payment Policy Manager - USA, Remote - $95,000 - $105,000

Payment Policy Manager

USA, Remote

$95,000 - $105,000

Job Description

It’s an exciting time to join our company, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

The Payment Policy Manager is responsible for managing cross-departmental implementation of changes to payment and billing policies as necessary due to regulatory changes, contractual changes, or as a result of claims data findings. The Payment Policy Manager will collaborate with internal departments to define requirements and to document those requirements sufficiently to ensure accurate implementation of payment rules within the Plan’s adjudication system, including the claim editing system, iCES. The Payment Policy Manager will also review current payment policies and compare them to those used by competitors, state regulatory agencies, and CMS to evaluate and recommend changes, and upon approval incorporate such changes into materials. As directed by the department manager, he/she will project manage regulatory changes that impact payment methods or rates, and help drive analytics to support decision-making. Additional specific duties and responsibilities include:

Our Investment in You:

·        Full-time remote work

·        Competitive salaries

·        Excellent benefits

Key Functions/Responsibilities:

·        Develops and maintains corporate payment policies, and works collaboratively with the Clinical Editing Manager to ensure consistency with the Plan’s adjudication system(s)

·        Monitors DHHS, EOHHS, and CMS websites, listservs and other sources to identify existing payment practice and upcoming changes. Determines the scope and impact of the change on Plan operations and seek to implement changes as necessary

·        Staffs and participates in various work groups and committees to support payment policies and provides input into processes and workflows reliant on payment policy outcomes

·        Serves as the department’s project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid payment regulations, Medicare Manual updates, DHHS and EOHHS fee schedules; and (2) regulatory issues. Determines the scope and impact of the information/issues and take appropriate action

·        Collaborates with Public Partnerships, Contracting, Medical Economics, Provider Relations, Benefit Administration, Business Configuration, and Provider Audit/OPL to determine the impact of implementing recommended policy changes

·        Develops project plans including: setting timelines and deliverables; determining resource requirements; documents decisions; draft communication plan; information-sharing with appropriate staff and seek approval from the Payment Policy Committee; and subsequently ensure successful completion of change

·        Serves as the company’s research specialist regarding Medicare and Medicaid payment policies.

·        Serves on the Operational Excellence Committee to ensure a consistent understanding of operational changes as they relate to payment policies and their downstream impact within the Claims department

·        Submits recommendations to the Payment Policy Committee and supports Committee efforts through subgroups and individually as needed

·        Collaborates with stakeholder departments to develop and maintain a database to serve a centralized location to store payment methodology information.

·        Researches, identifies and proposes opportunities for medical cost savings, improves claim auto adjudication rate and payment accuracy

Education:

·        Bachelor’s Degree in a related field or the equivalent combination of training and experience

Education Preferred/Desirable:

·        Master’s Degree or graduate work in a related field preferred

·        Coding Certification for Payers (CPC-P) preferred

·        AHIMA or other nationally recognized Coding Certification preferred

Experience:

·        6 or more years experience in a fast paced, managed healthcare environment is required.

·        6 or more years direct work in claims processing, payment policy, or contracting.

·        Extensive background of ICD-9 and CPT coding principles

·        Extensive knowledge of medical claim editing (NCCI, etc.)

·        Experience working with industry standard methods of payment including DRG, APC, RVU, etc.

·        Experience working with Medicaid, Medicare and commercial coding rules/ regulatory requirements.

Experience Preferred/Desirable:

·        Medical chart auditing

Competencies, Skills, and Attributes:

·        Demonstrated proficiency in coding and knowledge of the requirements of industry standards such as Medicare and/or Managed care regulations required.

·        Strong understanding of HIPAA Guidelines

·        Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation.

·        Expertise utilizing Microsoft Office products, including Project and PowerPoint

·        Knowledge of OptumInsight iCES product, or similar claims editing system