Candidates must be a resident of New Mexico to be considered for this role.
Who is Comagine Health?
Comagine Health is a national, nonprofit, health care consulting firm. We work collaboratively with patients, providers, payers, and other stakeholders to reimagine, redesign and implement sustainable improvements in the health care system.
As a trusted, neutral party, we work in our communities to address key, complex health, and health care delivery problems. In all our engagements and initiatives, we draw upon our expertise in quality improvement, care management, health information technology, analytics, and research.
We invite our partners and communities to work with us to improve health and redesign the health care delivery system.
Responsibilities
- Provide operational management of clinical staff who provide utilization review, and/or specialty reviews.
- Develop, implement, and maintain departmental policies and procedures, staffing protocols, training programs, quality management programs, and department budgets.
- Ensure that department fully meets all required legal, contractual and accreditation standards as well as compliance with corporate policies.
- Participate in business/product development, proposals and customer relations activities.
- Conduct prospective, concurrent, and/or retrospective utilization management reviews.
- Conduct performance appraisals with staff using objective data related to job performance and goals/standards established for each position.
- Ensure that all resource materials necessary to conduct daily work activities are made available to staff.
- Ensure that established quality, productivity and attendance standards are met by all staff through regular performance monitoring.
- Develop, update and share job descriptions with staff to clarify job expectations and performance standards.
- Initiate timely and appropriate counseling, education, training and coaching with staff to support professional development or to address areas of performance deficiencies and related improvement expectations.
- Responsible for all personnel management activities, including supervision, evaluation, hiring and termination, in accordance with company policies and under advisement of management.
- Serve as a consultant to staff regarding clinical and/or non-clinical matters, customer expectations, accreditation standards, contractual requirements and utilization activities, as applicable.
Quality Management
- Accept utilization management assignments when work volumes or case complexities require managerial back up.
- Collaborate with the development and implementation of a quality management program, including an on-going internal quality control (IQC) system.
- Collaborate with medical affairs and staff in developing guidelines and protocols for clinical review staff.
- Develop and implement necessary operational policies and procedures to meet contractual requirements, customer expectations, accreditation standards, and organizational needs.
- Monitor and maintain adequate access by providers, customers, patients/clients, and others with staff.
- Review Utilization Review reports, appeal letters, and other sensitive documents.
Financial Management
- Develop and monitor productivity standards for the staff.
- Develop timely and appropriate budgets that include sufficient staffing and other resources.
- Ensure compliance with finance and accounting policies and procedures.
- Initiate timely and appropriate managerial interventions to improve compliance with the budget.
- Monitor unbilled hours and open cases/reviews.
Customer Relations
- Participate in responses to requests for proposals (RFPs) and other business development activities.
- Promote, monitor, and improve positive customer service behaviors.
- Provide timely, appropriate, and responsive communications with providers, patients/clients, customers, and other stakeholders.
- Represent the products/services of the department through active participation in customer engagements.
Compliance and Administration
- Develop, monitor, and report on departmental goals, standards, and objectives.
- Ensure that the Vice President, Operations Director or designee is informed in a timely manner regarding significant operational issues.
- Maintain compliance with organizational policies and procedures.
- Monitor completion of timecards to ensure accuracy and compliance.
Compensation Range: $85,000 - $107,000
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