Albuquerque, NM, United States
Jun 18, 2021
Oct 01, 2021
The Compliance Professional 2 has responsibilities for performing clinical audits on medical record documentation for quality and clinical compliance with contract requirements as outlined in the Autism Care Demonstration (ACD) policy, TRICARE Operations Manual (TOM) Chapter 18 Section 4. Reviews shall compare the beneficiaries' session notes to the provider's claims to determine whether all required documentation exists and is adequate to support the submitted charges. Comprehensive medical reviews will be conducted on applied behavior analysis providers' claims for specified ABA CPT Codes.
95% Quality Monitoring
Review and assess necessary record components.
Complete assigned audits timely and in accordance with contract requirements
Maintain the web application tracking system to ensure all providers are in compliance based on the findings of their audits
Educate providers as appropriate on ACD policy requirements when improper or fraudulent billing or other potential fraudulent activity is identified; document findings and activities consistently, timely and accurately in designated system.
Engage Government Services local team as needed for provider education
Requires minimal direction and receives guidance where needed
Works collaboratively with PI and ACD leaders to determine any course of action, which would require a corrective plan due to lack of compliance for any of the requirements within the TOM
Utilizes established reporting and tracking tools to monitor audit outcomes and provider behavior
5% Other tasks as assigned
This role description in no way states or implies that the key accountabilities above are the only ones being performed by the individual(s) with this role description. The individual(s) may be called upon and required to follow other instructions or perform other duties and tasks requested by his or her supervisor, consistent with the purpose of the position, department and/or company objectives.
A current, valid, and unrestricted license to include: Licensed Clinical Social Worker (LCSW), Licensed Masters Social Worker (LMSW-ACP), Licensed Professional Counselor (LPC), Psychologist (PhD), Registered Nurse (RN) or other professional license
Minimum of 1 year of managed care experience
Experience with Microsoft Office products for business presentations including; Word, Excel, PowerPoint, Visio, Project, etc..
Excellent written and oral communication skills
Our Department of Defense Contract requires U.S. citizenship for this position
Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
Work at Home/Remote Requirements
Must ensure designated work area is free from distractions during work hours and virtual meetings
Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required
Prior experience in Compliance and/or Auditing
Prior TRICARE program knowledge and experience
Direct or Indirect Military experience
Direct or indirect experience with the Autism Care
Previous quality or process improvement experience
Detail orientated and comfortable working with tight deadlines in a fast paced environment
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Scheduled Weekly Hours
Website : http://www.humana.com