Nov 14, 2019
Who we are: Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry. We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide. Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities. A Day in the Life of a Supv, Business Monitoring: Supervises clinical review team members, ensures appropriate workload distribution and oversees day to day workflow processes. Acquires team monthly insights for improvement, develops insight tracking and delivery, and leads Interrater Reliability meetings. Continuously develops performance review tools to ensure validity of criteria, and appropriately captures evidence of expected clinical performance within contractual and Model of Care standards and produces optimal clinical and resource outcomes. Compiles and presents performance review trends and actively participates in department initiatives and projects. Trains team members in the review process for clinical performance.
Assists management in collaborating with Population Health Solutions, Operations and Information Technology departments to ensure full integration of reporting Monitors associate performance and conducts counseling/corrective action procedures when required. Identifies concerns, brings issues to management’s attention and offers suggestions for improvement Provides significant input to performance evaluation, hiring and termination decisions for associates in work group Reviews time records, sets schedules and approves all vacation/time off requests for subordinate associates Provides training and guidance to new and current reviewers regarding policy & procedure, systemic tools, workload and development Answers all questions and assists peers and management with delegated tasks or projects Takes the lead in preparing and submitting projects, reports or assignments as needed to meet department initiatives and/or objectives Leads in the development and ongoing review of clinical review tool to ensure that clinical elements accurately capture adherence with required performance standards Reviews Care Management program descriptions, policies and procedures, step actions, and training materials as well as State Contracts when needed to evaluate alignment of review tool elements, departmental processes, staff training, and contractual/departmental standards Utilizes clinical knowledge and experience to evaluate documentation of member health assessments, clinical needs and interventions in meeting compliance standards Participates in meetings with Care Management and others to discuss review findings, areas of opportunity and recommendations for improvement Appropriately escalates areas of concern identified during clinical file reviews Participates as needed with preparation for State, CMS, and NCQA audits by collecting and /or reviewing clinical areas of relevance Meets established productivity and IRR standards for file reviews Follows departmental guidelines and processes Creates Monthly Case Assignment List for Clinical team through regular roster verification Facilitates and organizes regular training IRR meetings for new Clinical team members Presents data findings to Clinical leadership Develops and Maintains Audit Reference Guide and Job Aids for clinical team members Records and tracks productivity for clinical team to report to manager on monthly basis Ensures completion of clinical team assignments through tracking and data compilation Conducts Care Management (UM, BH, CM, and/or DM) performance reviews by reviewing clinical documentation as assigned for Care Management for required clinical adherence as needed Other duties as assigned
What you can bring to Meridian: A Bachelor's Degree in Nursing, Clinical Social Work/Counseling, preferred 3+ years of experience in Managed Care (UM, BH, CM or DM), required Other, familiarity with Medicare and Medicaid programs, preferred Licenses/Certifications, preferred: Licensed Registered Nurse (RN) Licensed Practical Nurse (LPN) Licensed Certified Social Worker (LCSW) Licensed Marital and Family Therapist (LMFT) Licensed Mental Health Counselor (LMHC) Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions Ability to effectively present information and respond to questions from peers and management Ability to work independently Demonstrated time management and priority setting skills Ability to work in a fast paced environment with changing priorities Ability to drive multiple projects Demonstrated written communication skills Demonstrated interpersonal/verbal communication skills Ability to create, review and interpret treatment plans Demonstrated negotiation skills Ability to lead/manage others Knowledge of healthcare delivery Knowledge of NCQA, CMS, and state Medicaid requirements Ability to effectively present information and respond to questions from families, members, and providers Ability to effectively present information and respond to questions from peers and management Ability to implement process improvements Ability to analyze and interpret financial data in order to coordinate the preparation of financial records What Meridian can offer you: Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members. Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities. Meridian offers 401k matching that is above the national average. Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees. Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian. Equal Opportunity Employer #MSTR
Professional Diversity Network
Detroit, MI, USA