Correspondence Quality & Compliance Specialist

Role Overview

As a member of the Utilization Management Administrative Operations team, you will manage the UM letter approval process across the enterprise to include Medicare, Medicaid, CHIP, Exchange, and Behavioral Health. You will interface with internal teams and UM delegates to conduct quality reviews of UM letters templates and edit them as required to ensure adherence with NCQA and contractual requirements. 

Work Arrangement

• Remote role
• Monday through Friday, 8:00 AM EST to 5:00 PM EST

Responsibilities

• Acts as primary point of contact for all UM related letters for internal stakeholders and UM delegates.
• Provides current correct UM letter templates when required for UM delegation.
• Conducts pre-delegation review of delegate created UM Letter Templates for alignment with plan and/or state requirements.
• Ongoing letter audits for compliance with requirements.
• Works collaboratively with Plan Communications and Compliance for review and approval of templates for implementation and/or needed changes.
• Maintains UM letter library with current approved letter templates for both internal UM and clinical delegates, maintaining version control and archive of old, retired template versions.
• Reviews and provide final approval of for delegate letter templates.
• Conducts post go live review of live UM letter to confirm templates are as approved and letters are completed with appropriate content (including clinical rationale) in accordance with regulatory and/or accreditation requirements.
• Submits work requests when template changes are needed.
• Works with Clinical Delegation Oversight team to assist delegate in meeting all requirements for UM letter delegation.
• Provides feedback to the Clinical Delegation Oversight Team as necessary to support dwL and/or dCap.
• Interface with functional departments to address any template related issues.

• Interacts with various external entities, including plans, states, and vendors.

   

Education and Experience

• Registered Nurse or Licensed Clinical Social Worker required
  • Registered Nurse must have Associate's Degree in Nursing and a Bachelor's Degree or equivalent work experience 
  • Licensed Clinical Social Worker must have Master's Degree in Social Work
• Minimum of 3 years of utilization management experience, preferably for a payer
• Independent, direct clinical practice experience in acute care, post acute care, behavioral health, and homecare 
• Working knowledge of contractual and regulatory guidelines and rules for Medicare, Medicaid, CHIP, and Exchange

Licensure

• Active and unencumbered Registered Nurse license; NLC preferred
• Active and unencumbered Licensed Clinical Social Work (LCSW)

Skills and Abilities

• Displays good judgment in apprising management of situations that are incompatible with established policies for which there is little precedence
• Ability to work autonomously and as part of an interdisciplinary team 
• Ability to prioritize and manage multiple tasks/priorities simultaneously in a fast paced environment 
• Strong ability to create, monitor and analyze provider data
• Strong assessment, critical thinking and problem-solving skills

• Excellent verbal and written communication skills, including the ability to present to small groups

   

Our Comprehensive Benefits Package 

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.