Behavioral Health Compliance Specialist (Remote)

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.

Under the direction of the manager, assures that Behavioral Health staff performance is compliant with the various regulations and standards applying to utilization management operations.

These regulations include, CMS, NCQA and New Jersey Division of Banking and Insurance (NJ DOBI) and multiple state requirements.

In addition, the compliance specialist monitors the behavioral health review process to assure that staff are making appropriate medical necessity determinations, applying InterQual, ASAM and medical policy correctly, and making accurate and well-documented referrals to behavioral health medical directors, and documenting correctly for letter generation.

Involves providing business operations support for CMS and NCQA activities (survey, annual document preparation and maintenance) as well the various projects and initiatives for the Utilization Management Department. The behavioral health compliance specialist should communicate to management potential issues and trends that may be impacting and efficiency and quality.

Responsibilities Overview:

• Familiar with all aspects of operations in the Utilization Management Department.
• Serves as project lead for implementation of new processes and workflows, and for small based projects as delegated by the director/manager. Monitors effectiveness.
• Works to identify specific Quality Improvement Projects as required for CMS and NCQA generating base line and ongoing data for analysis.
• Acts as a resource for internal and external sources, utilizing excellent communication skills and responding in a timely and focused professional manner.
• Responsible for planning management meetings to review findings of compliance audits, potential training issues, process breakdown and to identify areas for areas for process improvement.
• Selects specific transactions and processes to be reviewed for compliance audits on a monthly basis and reports findings to Manager/supervisors.
• Through ongoing sample case review, assures that clinical staff is applying departmental policies and procedures correctly. Reports results of the monthly audit process to the staff, manager, and director, identifying strengths and opportunities for improvement. Provides feedback to the managers regarding probationary and annual staff reviews and status of corrective action plans when indicated.
• Assures that clinical staff are documenting appropriately in medical management system so that member letters are clear and understandable.
• Collaborates with the Quality Management, Regulatory Department and Clinical services operations to review policies and for annual review SME for Clinical Services for Regulatory and State Compliance Regulation.
• Participates in evaluation of policies and procedures and EDR/DLP and makes recommendations for improvement to service efficiency and quality of care.
• Through case review, assures that clinical staff are applying ASAM, InterQual and medical and departmental policy guidelines correctly and referring appropriate cases to medical directors. Assures that information provided to the medical director is relevant and helpful in making determinations.
• Assesses regulations and standards (CMS, NCQA, and STATE) and assures appropriate controls are in place, making recommendations and overseeing implementation of new controls where necessary.
• Assists the director/ manager in identifying training needs and assists in departmental training and the onboarding of new hires.
• Participates in team meetings as requested.
• Other duties as assigned.
• Maintains compliance information related to meeting State licensure requirements.
• Identifies process improvements and develops workflow and/or system recommendations.
• Leads quality Improvement Initiatives

Qualifications:

Education

One of the following is required: LCSW, or LPC or Active PA Licensed RN-BSN Preferred

Experience

Five (5) plus years of Behavioral Health clinical experience in a hospital or other health care setting. Prior Behavioral Health utilization management experience is desirable. Experience supporting quality management and/or compliance is strongly desired.

Required Skills:

• Excellent verbal and written communication skills with a key focus on attention to detail.
• Strong use of Excel, Power Point and Word.
• Must have strong interpersonal skills with demonstrated ability to provide associate feedback and support while maintaining positive, productive interpersonal relationships.
• Strong problem-solving abilities, organizational and planning skills.
• Experience adhering to CMS, NCQA and other programs requiring regulatory compliance.
• Knowledge of utilization review processes and utilization management systems, moderate to strong knowledge of InterQual required.

Fully Remote:
This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence’s physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.