[Remote] Clinical Compliance Program Manager at WellSky

United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

At least 4-6 years relevant work experience
Advanced working knowledge of CMS UM audits
At minimum, 2-3 years of compliance experience focused on CMS and health plan audits
At minimum, 1-2 years of implementing CMS final rule changes and managing change management of processes
Bachelor's Degree or equivalent work experience
Active, unrestricted license: RN, PT, OT or SLP, with a bachelor’s degree in a related field or a combination of education and experience that includes pertinent clinical experience and advanced working knowledge of CMS standards and guidelines (Preferred)
Experience with NCQA audits (Preferred)
Must be able to prioritize, plan and handle multiple tasks and demands simultaneously, with competing deadlines (Preferred)
Excellent in manipulating and sorting data for analytics and reporting (Preferred)
Prior experience owning client compliance SLAs and ensuring success in meeting SLA requirements (Preferred)

Responsibilities

Ensure compliance with WellSky's Utilization Management and Quality Improvement Program by serving as a clinical expert on state and federal regulations
Analyze and present data to establish best practices across post-acute health care settings
Facilitate activities related to performance measurement and outcomes
Ensure the organization meets CMS, NCQA, and other regulatory standards
Stay updated on relevant regulatory changes and support their integration into practices
Comply with state, federal, and organizational standards by assisting in the development and enforcement of policies aligned with Utilization Management and Quality Improvement Program requirements
Complete and successfully submit CMS reports: ODAG, Part C, Reopening, and Complaints and Grievance Reports
Conduct Root Cause Analysis (RCA) with Operational teams
Conduct regular compliance audits based on CMS UM standards for expedited, standard and other case statuses
Develop and guide the implementation of internal audit protocols in compliance with CMS regulations and NCQA standards
Contribute to the consistency of clinical documentation and decision-making processes
Generate and validate reports to monitor performance and compliance across health plan contracts
Prepare for regulatory, accreditation, and contractual audits, and contribute to the remediation and documentation of audit findings
Perform other job duties as assigned

Skills

WellSky

Healthcare software and community care solutions

About WellSky

WellSky offers software and services to improve health and community care, making it easier for providers and patients to access and navigate care. Its products, like the WellSky Value Based Care Suite, integrate with Electronic Health Record (EHR) systems to enhance care coordination. WellSky stands out by providing a comprehensive range of solutions, including strategic consulting and revenue cycle management, which help clients operate more efficiently. The company's goal is to enhance care delivery and improve individuals' quality of life through effective solutions.

Reston, VirginiaHeadquarters

1980Year Founded

$34.5MTotal Funding

DEBTCompany Stage

Social Impact, HealthcareIndustries

1,001-5,000Employees

Benefits

High deductible health plan with a generous employer contribution

PPO medical plan

Dental and vision insurance

401(k) plan with access to financial advisors who can provide personal financial guidance at no cost

Robust paid time off, including holidays, vacation, well-being, and volunteer days

Flexible spending accounts (medical and dependent)

Life and disability insurance

Educational assistance

Employee Assistance Plan with free and confidential emotional, financial, legal, and family resources

Risks

Integration challenges with acquisitions like Bonafide may cause operational inefficiencies.

Data privacy issues may arise from collaborations in the nonprofit sector.

Dependency on third-party systems increases exposure to partners' operational risks.

Differentiation

WellSky offers comprehensive solutions across the full continuum of care.

The company integrates with any EHR system to improve care coordination.

WellSky's services include strategic consulting, compliance, and revenue cycle management.

Upsides

Growing demand for integrated care solutions boosts WellSky's market potential.

Value-based care models align with WellSky's offerings, enhancing growth opportunities.

Acquisitions like TapCloud enhance patient engagement and reduce costs.

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