MLTSS Quality Assurance Specialist-Prior Authorization/Claims Resolution
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Job Summary:
Job Profile Summary
This position is responsible for reviewing assessment and quality oversight activities for the MLTSS/DSNP Quality Assurance program. This position will be responsible for contributing to the efficient functioning of the MLTSS/DSNP Quality Assurance program by supporting the management staff with clinical interface in on-going monitoring assignments and ensuring care management compliance requirements are met. The case file audits conducted by this position include the review of care management operations compliance to contractual requirements relative to the State Medicaid Contract, CMS, NCQA, HEDIS and STARS. This position is also responsible for following up on corrective action plans based on audit data, and preparing periodic and year-end State and internal reports
Job Description
Responsibilities:
- Responsible for conducting audits on member charts, including assessments (at least quarterly) for all areas of MLTSS/DSNP care management operations, which review daily business practice compliance to regulatory requirements relative to the State Medicaid Contract funded in part by the Centers for Medicare and Medicaid Services (CMS).
- Analyzes, prepares, documents and distributes audit reports/outcomes, including error trends, to the MLTSS/DSNP Department management for follow-up with care management staff; and conducts follow up reviews of corrective action.
- Comprehensively collaborates with the MLTSS/DSNP Department to review outcomes and then develop process improvement recommendations and changes as well as the need for and provision of continuous education/training opportunities.
- Presents MLTSS/DSNP Quarterly Audit and other Targeted Audit Reports and supporting findings during MLTSS/DSNP Subcommittee meetings of which the MLTSS Medical Director and other Directors are voting members.
- Organizes and prioritizes multiple projects within MLTSS/DSNP oversight activities, under the direction of the MLTSS/DSNP Manager, and communicates internally, with the MLTSS/DSNP Department and the Quality Management Department, as well as externally through attendance at State quality meetings, to recognize MLTSS program-wide improvement initiatives and participate in the implementation of strategies to improve the MLTSS/DSNP Program within HNJH.
- Conducts periodic targeted audits of various components of the MLTSS/DSNP program, against business process flows in order to evaluate compliance with MLTSS/DSNP standards.
- Responsible for collaborating with Analytic staff in the development of MLTSS/DSNP tool(s). These efforts include testing the audit tool, communicating feedback, and ensuring timelines are established and met.
- Develops/Assists with creating internal workflows to establish standardized guidelines for audits and other internal processes.
Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.
Education/Experience:
- High School Diploma/GED required
- Bachelor degree preferred or relevant experience in lieu of degree
- Requires a minimum of 3 years experience in the health care delivery system/industry.
- Prefers three (3) years managed care experience in a customer-oriented capacity.
- Requires experience in chart reviews, indicators and databases.
- Working knowledge or regulatory agency standards and requirements desired.
- Requires quality initiative experience.
- MLTSS experience strongly preferred.
Additional licensing, certifications, registrations:
- Preferred Licensed Registered Nurse.
Knowledge:
- Required knowledge of medical terminology.
- Prefers knowledge of managed care principles.
- Requires knowledge of managed care health care delivery systems.
- Requires knowledge of performing chart audits or clinical chart audits.
- Requires compliance experience or long term care experience
- Prefer exposure to data compilation and presentation processes.
- Proficient knowledge of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook; client tracking and other electronic verification systems.
- Proficient knowledge of audit methodologies and procedures such as drawing random samples, creating graphs, and writing descriptive analyses to illustrate findings and make projections.
- Knowledge of the parameters for conducting the State specified Home Care Assessment system which determines clinical eligibility for program enrollment and is the foundation for the MLTSS plan of care.
- Claims experience strongly preferred
- FACETS experience strongly preferred
Skills and Abilities:
- Requires strong PC skills with a demonstrated accuracy.
- Requires excellent verbal and written communication skills.
- Requires solid organization of multiple tasks, time and work processes
- Requires strong analytical and problem Solving skills
- Effective process management techniques.
- Strong interpersonal & teambuilding relationship skills.
- Strong presentation skills, both verbally and in writing/reports.
Salary Range:
$76,800 - $102,795
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
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Comprehensive health benefits (Medical/Dental/Vision)
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Retirement Plans
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Generous PTO
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Incentive Plans
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Wellness Programs
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Paid Volunteer Time Off
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Tuition Reimbursement
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
What We Do
Horizon Blue Cross Blue Shield of New Jersey- the state’s largest and oldest health insurer - is a subsidiary of Horizon Mutual Holdings, Inc., a not-for-profit mutual holding company.
Together with its affiliates, Horizon provides a wide array of medical, dental, vision and prescription insurance products and services. As New Jersey’ health solutions leader, Horizon is transforming healthcare by working with doctors and hospitals to deliver innovative, patient-centered programs that improve quality and lower costs. It is headquartered in Newark, NJ with offices in Wall and Hopewell, NJ.
Horizon serves 3.7 million members including more than 1 million who rely on Medicaid for their health coverage.
