Job Description

As the Manager, Clinical Compliance, you will lead your staff to an exceptional performance level by giving quality objectives and opportunities to expand their knowledge of services, products, and troubleshooting techniques which will focus on improving performance and processes in an effort to better support customers and internal department procedures.

WHAT YOU’LL BE DOING

• Directly manage staff responsible for routine monitoring and audits of clinical procedures.
• Determine the Compliance Departments operational strategies by conducting assessments, capacity planning, and cost/benefit analyses; identifying and evaluating state-of-the-art technologies; defining user requirements; establishing technical specifications, production, productivity, quality and data entry standards; contributing information and analysis to organizational strategic plans and reviews with standard performance metrics.
• Maintains and improves Compliance Department processing operations by monitoring system performance; identifying and resolving problems; preparing and completing action plans; managing system and process improvement and quality assurance programs.
• Assessing and assigning workflow, coaching, counseling, and disciplining employees; administering scheduling systems and processes; communicating job expectations; planning, monitoring department measures, conducting staff performance conversations; enforcing policies and procedures.
• Ensure department audit scores meet requirements and consistently meet the expectations of the MSA and UM Plan.
• Play a key role in the development of the Annual UM and PHM Plans, MCG Guidelines and reports, and UM Packets.
• Understand and stay current with the clinical requirements of the MSA and UM Plan, ensuring Guidehealth remains compliant as well as meet client expectations.
• Responsible for formulating professional development and educational plans for Compliance staff.
• Coordinate compliance activities with other internal functions alongside departments and managers.
• Conduct at minimum monthly meetings with direct reports and annual personnel reviews on staff performance.
• Attend client facing meetings as requested to discuss department statistics and measures.
• Maintain and report monthly and annual department Key Performance Indicators (KPI’s).
• Monitor internal and external processes to detect any practices that, either directly or indirectly, result in fraud, abuse or waste that results in unnecessary costs.
• Coordinate yearly notification of availability to care letters with third party vendors and client business managers.
• Assist with, and understand all department audits including Intake audits, Referral Coordinator audits, Population Health audits, Utilization Review audits and QI audits.
• Coordinate and review final Semiannual Audit Submissions
• Maintains professional appearance while on camera meetings.
• Other duties and responsibilities as assigned.

Qualifications

WHAT YOU’LL NEED TO HAVE

• 2-5 years of direct management experience in Healthcare insurance platforms including clinical experience, professional analytics-related experience and experience working on/managing major projects.
• Minimum 1-3 years of experience in the healthcare or managed care industry, including clinical experience, auditing, professional analytics-related experience and experience working on/managing major projects.
• 1-3 years auditing experience in the healthcare industry.
• Prior experience with MCG CareWeb QI.
• CPT and ICD coding knowledge.
• Proficient with Microsoft programs (Word, Excel and Access) at an intermediate to advanced level.
• Must be organized, self-motivated, detail oriented, disciplined and a team player
• Demonstrates the ability to manage staff and multi-task with minimum supervision and the ability to prioritize appropriately.
• Able to problem solve, exercise initiative and make medium to high level decisions.
• Thorough understanding of current federal, state and local healthcare compliance requirements.
• Ability to meet deadlines and prioritize tasks; to effectively interact with operational and clinical personnel; collect, correlate and analyze data
• Excellent written and oral communication.

WHAT WE'D LOVE FOR YOU TO HAVE

• Clinical degree of RN, LPN or higher.
• Microsoft Access experience level – Advanced.

Additional Information

The salary range for this position is $55,000.00 to $65,000.00 per year.

ALIVE with Purpose: How We Thrive at Guidehealth

At Guidehealth, our values come to life in everything we do.

• We are Driven by A ccountability — grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike.
• Always Growing, Always L earning — staying curious and continuously improving inspires us to shape a better future for healthcare.
• With Collaborative I nnovation, we solve problems creatively, making every experience better for our employees and the patients we serve.
• At Guidehealth, Every V oice Matters — we believe our collective strength is rooted in the unique perspectives of each team member.
• And through E mpathy in Action, we build stronger connections with those who count on us.
• This is what it means to be ALIVE with purpose. This is how we thrive — together — at Guidehealth.

BENEFITS:

All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:

• Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
• Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
• Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
• Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
• Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
• Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
• Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.

COMPENSATION:

The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.

OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT

Diversity, inclusion, and belonging are at the core of Guidehealth’s values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race, religious creed, color, age, sex, sexual orientation and identity, national origin, citizenship, religion, marital status, familial status, physical, sensory, or medical disability, Family and Medical Leave, military or veteran status, pregnancy, childbirth or other related medical conditions, or any other classification protected by federal, state, and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring, placement, promotion, transfer, demotion, layoff, termination, recruitment advertising, pay, and other forms of compensation, training, and general treatment during employment.

OUR COMITTMENT TO PROTECTION OF PATIENT AND COMPANY DATA

This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealth’s custodianship as well as Guidehealth Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.

REMOTE WORK TECHNICAL REQUIREMENTS

Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection, capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 50 mbps download, 10 mbps upload. Please consult with your internet provider or run a speed test here to confirm your internet connection meets these requirements.