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Clinical Pharmacist Advisor (Medicare Part D) – REMOTE
✦ New
Salary not disclosed
Clinical Pharmacist Advisor – Medicare Part D (REMOTE) Location: 100% Remote (U.S.) Pay Rate: $53.00/hr Schedule: Set rotation within business hours (see below) Opportunity: Contract with potential for full-time conversion About the Role We are hiring 50 Remote Clinical Pharmacist Advisors to support Medicare Part D members and providers in a fast-paced, high-volume, production-driven environment.
This role is ideal for pharmacists with prior authorization, managed care, or PBM experience who thrive in a structured, remote setting.
As a Clinical Pharmacist Advisor, you will review pharmacy benefit requests, make clinical determinations, and ensure compliance with CMS and Medicare guidelines while delivering best-in-class service.
Key Responsibilities Review and process prior authorizations, coverage determinations, and appeals Evaluate clinical documentation to support approval/denial decisions Ensure all cases meet Medicare Part D and CMS compliance standards Conduct provider outreach to obtain additional clinical information Document all decisions clearly and accurately in system workflows Manage high-volume queues while meeting productivity and quality metrics Apply clinical knowledge using drug compendia and established guidelines Required Qualifications Active Pharmacist license in state of residence (in good standing) PharmD or Bachelor’s Degree in Pharmacy Strong computer skills (Excel, Word required; Access, PowerPoint, Visio preferred) Experience with data entry, dual screens, and multiple systems Ability to work independently in a productivity-driven remote environment Strong attention to detail and documentation accuracy Preferred Experience Managed Care / PBM experience Prior Authorization, Coverage Determinations, or Appeals Medicare Part D knowledge and CMS guideline familiarity Remote pharmacist or high-volume review experience Retail + Managed Care hybrid background Schedule & Training Requirements Training: Monday–Friday, 9:00 AM – 5:30 PM EST (first 8 weeks – no time off allowed) Post-Training Schedule: Business Hours: 7:00 AM – 8:00 PM EST (Mon–Fri) Weekends: 7:00 AM – 4:30 PM EST Must be flexible to work assigned 8-hour shifts, including weekends Work Environment Requirements (MANDATORY) Dedicated, quiet, private workspace Wired internet connection: Minimum 25 Mbps download / 5 Mbps upload Speed test screenshot required (must be included on resume) Ability to remain on camera during training and team meetings Ability to sit and focus for full shift with minimal interruptions Submission Requirements (MUST BE INCLUDED ON RESUME) Screenshot of internet speed test ( ) Screenshot of active pharmacist license (showing name, state, expiration) Completed candidate questionnaire (see below) Candidate Pre-Screen Questionnaire (Include with Submission) Are you available for full-time training (M–F, 9–5:30 EST) for 8 weeks with no time off? Can you work any assigned 8-hour shift between 7 AM – 8 PM EST, including weekends? Do you have a dedicated, quiet workspace for remote work? Do you have wired internet meeting 25/5 Mbps requirements? Can you sit and focus for the entire shift without interruptions? Do you have experience with data entry and multiple systems/screens? Do you have an active pharmacist license in your state of residence? Are you comfortable working independently in a productivity-based role? Do you bring a positive, engaged attitude to a team environment? We are hiring 50 Remote Clinical Pharmacist Advisors to support Medicare Part D members and providers in a fast-paced, high-volume, production-driven environment.
This role is ideal for pharmacists with prior authorization, managed care, or PBM experience who thrive in a structured, remote setting.
As a Clinical Pharmacist Advisor, you will review pharmacy benefit requests, make clinical determinations, and ensure compliance with CMS and Medicare guidelines while delivering best-in-class service.
Key Responsibilities Review and process prior authorizations, coverage determinations, and appeals Evaluate clinical documentation to support approval/denial decisions Ensure all cases meet Medicare Part D and CMS compliance standards Conduct provider outreach to obtain additional clinical information Document all decisions clearly and accurately in system workflows Manage high-volume queues while meeting productivity and quality metrics Apply clinical knowledge using drug compendia and established guidelines
Remote working/work at home options are available for this role.
This role is ideal for pharmacists with prior authorization, managed care, or PBM experience who thrive in a structured, remote setting.
As a Clinical Pharmacist Advisor, you will review pharmacy benefit requests, make clinical determinations, and ensure compliance with CMS and Medicare guidelines while delivering best-in-class service.
Key Responsibilities Review and process prior authorizations, coverage determinations, and appeals Evaluate clinical documentation to support approval/denial decisions Ensure all cases meet Medicare Part D and CMS compliance standards Conduct provider outreach to obtain additional clinical information Document all decisions clearly and accurately in system workflows Manage high-volume queues while meeting productivity and quality metrics Apply clinical knowledge using drug compendia and established guidelines Required Qualifications Active Pharmacist license in state of residence (in good standing) PharmD or Bachelor’s Degree in Pharmacy Strong computer skills (Excel, Word required; Access, PowerPoint, Visio preferred) Experience with data entry, dual screens, and multiple systems Ability to work independently in a productivity-driven remote environment Strong attention to detail and documentation accuracy Preferred Experience Managed Care / PBM experience Prior Authorization, Coverage Determinations, or Appeals Medicare Part D knowledge and CMS guideline familiarity Remote pharmacist or high-volume review experience Retail + Managed Care hybrid background Schedule & Training Requirements Training: Monday–Friday, 9:00 AM – 5:30 PM EST (first 8 weeks – no time off allowed) Post-Training Schedule: Business Hours: 7:00 AM – 8:00 PM EST (Mon–Fri) Weekends: 7:00 AM – 4:30 PM EST Must be flexible to work assigned 8-hour shifts, including weekends Work Environment Requirements (MANDATORY) Dedicated, quiet, private workspace Wired internet connection: Minimum 25 Mbps download / 5 Mbps upload Speed test screenshot required (must be included on resume) Ability to remain on camera during training and team meetings Ability to sit and focus for full shift with minimal interruptions Submission Requirements (MUST BE INCLUDED ON RESUME) Screenshot of internet speed test ( ) Screenshot of active pharmacist license (showing name, state, expiration) Completed candidate questionnaire (see below) Candidate Pre-Screen Questionnaire (Include with Submission) Are you available for full-time training (M–F, 9–5:30 EST) for 8 weeks with no time off? Can you work any assigned 8-hour shift between 7 AM – 8 PM EST, including weekends? Do you have a dedicated, quiet workspace for remote work? Do you have wired internet meeting 25/5 Mbps requirements? Can you sit and focus for the entire shift without interruptions? Do you have experience with data entry and multiple systems/screens? Do you have an active pharmacist license in your state of residence? Are you comfortable working independently in a productivity-based role? Do you bring a positive, engaged attitude to a team environment? We are hiring 50 Remote Clinical Pharmacist Advisors to support Medicare Part D members and providers in a fast-paced, high-volume, production-driven environment.
This role is ideal for pharmacists with prior authorization, managed care, or PBM experience who thrive in a structured, remote setting.
As a Clinical Pharmacist Advisor, you will review pharmacy benefit requests, make clinical determinations, and ensure compliance with CMS and Medicare guidelines while delivering best-in-class service.
Key Responsibilities Review and process prior authorizations, coverage determinations, and appeals Evaluate clinical documentation to support approval/denial decisions Ensure all cases meet Medicare Part D and CMS compliance standards Conduct provider outreach to obtain additional clinical information Document all decisions clearly and accurately in system workflows Manage high-volume queues while meeting productivity and quality metrics Apply clinical knowledge using drug compendia and established guidelines
Remote working/work at home options are available for this role.
Not Specified
Attorney Manager, Appeals & Rebuttals
✦ New
Salary not disclosed
Attorney Manager, Appeals & Rebuttals
A healthcare services organization is seeking an attorney-trained leader to manage provider and supplier enrollment appeals and rebuttals in a CMS-regulated Medicare environment. This is a law-degree-required management role responsible for overseeing appeal and rebuttal operations, guiding attorney-level written work, evaluating complex case records, and ensuring outcomes are timely, well-documented, and aligned with CMS guidance, contractual requirements, and internal procedures.
Candidates must have a J.D. and/or LL.M. from an ABA-accredited law school plus post-law-degree experience in administrative law or legal writing and research. Candidates without these qualifications will not be considered.
This role is a remote, permanent opportunity with occasional travel as needed for client-related meetings.
Applicants without the required law degree and post-law-degree legal experience will not be considered.
Compensation:
- Base salary: $100,000 to $130,000
- Bonus: 10% target bonus
Work Model:
- Remote
- Approved hiring states only: AL, FL, GA, MS, NC, SC, TX, or PA
- Preference for candidates near Northeast Florida or Mechanicsburg, PA, but this is not required
- Travel may be required based on client needs, though frequency is not yet defined
Position Overview:
The Attorney Manager, Appeals & Rebuttals, leads the day-to-day management of provider and supplier enrollment appeal and rebuttal operations in a structured Medicare environment. This role requires strong legal writing and research capability, sound regulatory judgment, disciplined execution, and the ability to manage complex administrative case workflows with consistency and precision.
This individual will supervise approximately 4 to 6 direct reports, maintain performance metrics for timeliness and quality, and partner closely with leadership, compliance, and legal stakeholders to support accurate, evidence-based case outcomes.
This is not a general healthcare operation, grievance-only, provider enrollment-only, paralegal, claims, revenue cycle, or compliance-only management role. It is a law-degree-required legal operations role for candidates with attorney-level writing, research, and administrative review experience.
Key Responsibilities:
Legal Operations, Leadership, and Compliance:
- Lead daily operations for provider and supplier enrollment appeals and rebuttals in a CMS-regulated environment
- Supervise and develop a small team responsible for appeal and rebuttal workflow, written case development, quality review, and administrative case processing
- Maintain team performance metrics tied to timeliness, quality, and compliance expectations
- Review complex appeal and rebuttal matters, assess facts and documentation, and guide consistent, well-supported outcomes aligned with CMS guidance and contractual requirements
- Ensure appeal and rebuttal narratives are supported by evidence, policy, and regulatory requirements
- Translate contractual and regulatory updates into operational workflows, written procedures, and team guidance
- Identify trends, risks, and process improvement opportunities and escalate issues as appropriate
- Support development and maintenance of documentation standards, administrative record quality, and defensible case handling practices
Appeals and Rebuttal Strategy:
- Lead strategy for appeal and rebuttal responses involving provider and supplier enrollment determinations
- Oversee the preparation and review of written narratives, case summaries, and supporting documentation
- Establish and maintain processes that promote timely, accurate, and compliant case handling
- Use workflow and performance data to identify recurring issues, improve quality, and strengthen operational consistency
- Incorporate findings into training, process updates, and policy refinement
Cross-Functional Collaboration:
- Serve as a subject matter resource and escalation point for internal leaders and partner teams
- Coordinate with internal and external legal stakeholders on documentation, case strategy, and administrative record development
- Support interactions with federal client stakeholders as needed regarding appealable and rebuttable determinations
- Collaborate across teams to improve upstream processes and reduce avoidable appeal volume
- Present trends, risks, and recommendations to senior leadership
Required Qualifications:
- J.D. and/or LL.M. from an ABA-accredited law school
- 3+ years of experience in administrative law or post-J.D./post-LL.M. legal writing and research
- 5+ years of supervisory or team leadership experience in legal writing, legal research, and/or administrative law
- Demonstrated ability to make objective decisions in a structured, high-compliance environment
- Experience analyzing workflows and performance data to improve operations and support regulatory compliance
- Strong verbal and written communication skills
- Ability to collaborate effectively across leadership, compliance, legal, and partner teams
- Ability to pass an additional Government ICT background investigation required for access to government systems
Preferred Qualifications:
- Supervisory or management experience in a Medicare production environment
- Experience supporting provider or supplier enrollment appeals, rebuttals, or related regulatory operations
- Experience working with CMS guidance, federal program requirements, and contractual service obligations
- Experience managing teams responsible for structured case review, written determinations, or administrative review workflows
Ideal Background:
- Prior experience leading structured appeals or rebuttal workflows in a highly regulated environment
- Strong legal writing and documentation discipline
- Experience reviewing complex records, applying policy and regulatory requirements, and guiding consistent outcomes
- Experience operating in environments where timeliness, quality, compliance, and audit readiness are critical
- Comfort working in a highly structured role with repetitive review responsibilities and clear performance expectations
Additional Information:
- Approximately 4 to 6 direct reports
- Role supports a function required by a federal client
- Travel may be needed for client-related meetings
- Start timing is flexible for the right candidate
Application:
Candidates with an ABA-accredited J.D. and/or LL.M., attorney-level legal writing and research experience, and management experience in administrative law or regulated healthcare appeals environments are encouraged to apply.
Applicants without the required law degree and post-law-degree legal experience will not be considered.
Not Specified
Manager of Enrollment & Reconciliation
✦ New
Salary not disclosed
Manager of Enrollment & Reconciliation -
HealthCare Support is seeking a Manager of Enrollment & Reconciliation to support a Medicare Advantage Plan, delivering accessible, culturally attuned healthcare to the diverse populations it serves in Huntington Beach, CA!
Schedule
- Monday- Friday, 8am-5pm with 1-day onsite per week
Compensation
- $90,000 - $110K annually (depending on experience)
Daily Responsibilities
- Oversee and optimize all Medicare Advantage enrollment and reconciliation processes to ensure accuracy, compliance, and operational efficiency.
- Serves as the organization's expert on CMS rules, MARx transactions, eligibility policies, retroactive adjustments, and payment reconciliation requirements.
- Leads the team by setting priorities, guiding goals, and ensuring high?quality data capture and reporting.
- Manages MARx transaction processing, resolves rejections, reconciles CMS response files, and ensures alignment between internal systems and downstream partners like PBMs, claims, and finance.
- Identifies discrepancies, maintains governance around enrollment and payment accuracy, and ensures timely corrective actions.
Qualifications
- Bachelor's degree or equivalent combination of education and experience.
- 2 years of enrollment and reconciliation supervisory experience.
- 4 years of Medicare Enrollment experience at the health plan level.
- Experience Medicare Advantage Enrollment and Reconciliation rules and regulations, including CMS enrollment policy, MARx processing, payment reconciliation, and audit requirements.
- Expert-level knowledge of Medicare Advantage audit, compliance, enrollment, reconciliation, and regulatory reporting requirements
- Expert knowledge of Medicare Advantage enrollment transactions, reconciliation processes, and CMS enrollment policy.
- Advanced understanding of MARx transaction codes, CMS response files, and enrollment reconciliation workflows.
Interested in this opportunity?
Click Apply Now for immediate consideration, or reach out to our Recruiter, Melanie Williams with any questions:
- Call: (4
- Email:
- Schedule a Call: Support Staffing, LLC is an equal employment opportunity employer and will consider all qualified applicants without regard to race, color, religion, disability, sex, sexual orientation, gender identity, national origin, protected veteran status, or any other characteristic protected by applicable local, state, or federal law.
Not Specified
N
Quality Control Scientist
✦ New
Salary not disclosed
Details:
Job Title: API EM Quality Assurance Professional
Location: Indianapolis, IN
Duration: 12+ Months Contract (extendable)
Pay Range: $70 - $77 per hour on W2.
Qualifications:
At Client, we serve an extraordinary purpose. We make a difference for people around the globe by discovering, developing and delivering medicines that help them live longer, healthier, more active lives. Not only do we deliver breakthrough medications, but you also can count on us to develop creative solutions to support communities through philanthropy and volunteerism.
Join the energetic and growing Active Pharmaceutical Ingredient - External Manufacturing Organization (API-EM) that delivers a diverse portfolio of medicines essential to our patients around the world. The API EM Quality Assurance for Quality Control provides support to all QC activities at Contract Manufacturing organizations (CMs). The QA for QC position is essential for ensuring that all QC testing is in accordance with the validated methods and are compliant to cGMPs and regulatory commitments.
Basic Requirements:
• BS in a science-related field such as Pharmacy, Chemistry, Biological Sciences or related Life Sciences.
• 5+ years of GMP Quality Control Laboratory knowledge and/or experience in API or finished product manufacturing, QA or Engineering.
• Additional Preferences:
• Testing experience with Small Molecule
• Thorough technical understanding of quality systems and regulatory requirements relating to quality control laboratories
• Knowledge of pharmaceutical manufacturing operations.
• Demonstrated coaching and mentoring skills.
• Experience in root cause analysis.
• Demonstrated application of statistical skills.
• Demonstrated strong written and verbal communications skills.
• Strong attention to detail.
• Proficiency with computer system applications.
• Excellent interpersonal skills and networking skills.
• Ability to organize and prioritize multiple tasks.
• Ability to influence diverse groups and manage relationships.
Education Requirements:
• BS in a science-related field such as Pharmacy, Chemistry, Biological Sciences or related Life Sciences.
Other Information:
• Must complete required training for API EM Quality Assurance.
• No certifications required.
• Tasks require entering manufacturing and laboratory areas which require wearing appropriate PPE.
• Must be able to support 24 hour/day operations.
• Up to 20% travel US & OUS.
Responsibilities:
Key Objectives/Deliverables:
• Serve as a liaison between CMs and Client.
• Provide quality oversight of Quality control activities at CMs including being the initial point of contact for all quality-related issues with testing.
• Provide quality oversight of CM method validation or method transfer activities
• Escalate quality issues at CMs to Client's QA management.
• Assist in the establishment and revisions of Quality Agreements with affiliates and customers.
• Ensure compliance to Quality Agreements and Manufacturing Responsibilities Documents (MRDs).
• Coordinate and perform quality responsibilities of API shipments for stability testing. Provide quality oversight of API EM stability program.
• Participate in regulatory inspection preparations with CMs.
• Ensure that documented checks have been completed for the Certificates of Testing and Certificates of Environmental Monitoring (where applicable), and deviations, changes and batch documentation that demonstrates requirements have been met prior to batch release.
• Provide quality support of Quality Control with the focus on holistic review of key activities associated with or impacting the quality control testing including deviations, change controls and countermeasures.
• Assess the impact of analytical deviation investigations and changes and ensure that all appropriate records are documented and retrievable.
• Maintain awareness of external regulatory agency findings which individually or collectively reference the quality of the product.
• Review and approve documents including, but not limited to, analytical procedures, change control proposals, deviations, analytical equipment qualifications, analytical methods and computerized system validations.
• Participate in APR activities.
• Participate in projects to improve productivity.
• Participate in Joint Process (JPT) and Post Launch Optimization (PLOT) Teams.
Not Specified
MDS Coordinator
✦ New
Salary not disclosed
Position Summary
The LPN/RN MDS Coordinator coordinates and assists with completion and submission of accurate and timely interdisciplinary MDS Assessments, CAAs, and Care Plans according to CMS RAI Manual Regulations and in accordance with all applicable laws, regulations, and Life Care standards.
Education, Experience, and Licensure Requirements
- Associate or bachelor’s degree in nursing from an accredited college or university
- Currently licensed/registered in applicable State. Must maintain an active Registered Nurse (RN) license in good standing throughout employment.
- Two (2) years’ nursing experience. Geriatric nursing experience preferred.
- CRN C Certification (clinical compliance)
- CPR certification upon hire or obtain during orientation. CPR certification must remain current during employment.
Specific Job Requirements
- Advanced knowledge in field of practice
- Make independent decisions when circumstances warrant such action
- Knowledgeable of practices and procedures as well as the laws, regulations, and guidelines governing functions in the post-acute care facility
- Implement and interpret the programs, goals, objectives, policies, and procedures of the department
- Perform proficiently in all competency areas including but not limited to: patient rights, and safety and sanitation
- Maintains professional working relationships with all associates, vendors, etc.
- Maintains confidentiality of all proprietary and/or confidential information
- Understand and follow company policies including harassment and compliance procedures
- Displays integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training
Essential Functions
- Coordinate and assist with completion and submission of interdisciplinary, accurate, and timely MDS Assessments, CCAs, and Care Plans according to CMS RAI Manual Regulations
- Report any changes in a patient’s condition identified by the MDS Assessment to the DON
- Provide education to direct care associates regarding updates or changes to the CMS RAI Manual or Skilled Nursing Facility Regulations that impact documentation
- Assist with review of the Interdisciplinary Comprehensive Care Plan
- Review Final Validation Reports and attest that all assessments have been completed and accepted into the CMS QIES system prior to billing and notify the Business Office when assessments are not ready to bill
- Review CMS Reports to identify assessments completed or submitted late and develop systems and processes to prevent reoccurrence
- Attend and participate in the Daily PPS Meeting, Monthly Triple Check, and other meetings upon request
- Perform functions of a staff nurse as required
- Exhibit excellent customer service and a positive attitude towards patients
- Assist in the evacuation of patients
- Demonstrate dependable, regular attendance
- Concentrate and use reasoning skills and good judgment
- Communicate and function productively on an interdisciplinary team
- Sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
- Read, write, speak, and understand the English language
An Equal Opportunity Employer
Not Specified
Senior Coding Educator
Salary not disclosed
Hourly Pay Range:
$32.60 - $48.90 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.
Position Highlights:
* Position: Senior Coding Educator
* Location: Skokie, IL
* Full Time
* Hours: Monday-Friday, 8:00am-4:30pm
A Brief Overview:
The purpose of this job is to educate physicians, other qualified billing providers, and ancillary staff on their documentation for all specialties and review providers progress notes, as needed, to ensure coding/billing compliance in accordance with coding rules, third party payor guidelines, governmental regulations, and MG's Coding Compliance Program. The Senior Analyst will conduct face-to-face summary review sessions to report findings to the Practice Manager, Provider audited, and/or Senior Management of the MG. Through the audit/review process, this person will also conduct a report back to the provider and practice manager any income enhancing opportunities that might be uncovered in the investigation. The Senior Analyst, as a coding and billing expert, will assist all freestanding and provider-based outpatient departments with ICD-10, CPT-4, and HCPCS coding education and billing regulation interpretation. They will also assist in conducting department presentations.
What you will do:
* Analyzes progress notes, op reports, pathology reports, encounter forms, explanation of benefits, patient insurance information, and various other health information documents for pro-fee coding and billing accuracy.
* Assigns appropriate ICD-10, CPT, and HCPCS codes to medical record documentation under review by applying physician specialty coding rules, third party payor guidelines, and Medicare Local Medical Review Policies.
* Assists Manager/Director with providing information to the physician or medical specialty based on the Office of Inspector General's (OIG) and Centers for Medicare and Medicaid Services (CMS) risk areas. Reads the OIG's Semi-Annual reports and the OIG'S/CMS's Annual Workplan, in addition to notifications published on government websites.
* Performs physician and departmental documentation reviews based on industry standard coding and billing guidelines and payer policies to provide documentation and workflow improvement opportunities.
* Works with MG physicians or clinic personnel, HIRS, to interpret medical record documentation and/or documentation summary as necessary.
* Works with Customer Service and MG Operations to review and resolve escalated patient coding disputes.
* Works collaboratively with Billing, HIRS, overseeing provider/specialty and Denials Management Team to provide educational and/or income enhancing opportunities when issues are identified by those teams.
* Conducts educational sessions with Site Directors, Practice Managers, and providers on frequently seen coding errors in their site and assists with implementing changes to improve coding quality and minimize compliance risk.
* Provides feedback to Manager/ Director that identifies inefficient coding/operational processes.
* Assists with related special projects as assigned by Manager/ Director.
* Initiate and provide coding education to all MG billing providers, focusing on Evaluation and Management (E&M) documentation and billing requirements, as well as any specialty-specific coding guidelines.
* Works on special projects with the Hospital Billing Business Office and/or the Finance Department to perform reimbursement analysis functions as assigned by Manager/ Director.
* Submits ideas to Manager of Coding Quality & Auditing departmental newsletter based on coding/billing issues, coding help-line questions, or results of provider audits. May produce Monthly Newsletter if assigned.
* Participates in Coding and Business Operation Education in-services assigned by Manager
* Researches multi-specialty coding and billing questions received from the Coding Help-line/email for EHMG provider/staff and provides verbal or written response as appropriate. Maintains filing system of all questions received and answers provided to caller.
* Identifies trends or patterns of questionable coding and billing practices at Hospital Outpatient and Medical Group sites and reports issues to Manager.
* Reports compliance concerns to Manager or compliance hotline according to the Endeavor Healthcare Corporate Compliance Policy/Procedures.
* Develops physician coding tools such as ICD-10 and CPT-4 cheat sheets, coding grids, tip sheets and other educational material for multi-specialty providers to identify appropriate codes or modifiers reimbursed by payers for services performed.
* Assists in the creation of progress note templates per specialty utilizing the CMS documentation regulations or CPT Assistant guidelines as requested by physician's) or assigned by supervisor.
* Attends multi-specialty physician coding, billing, reimbursement seminars to maintain and increase coding, billing, reimbursement expertise/ knowledge.
* Maintains coding credential by obtaining the requiring continuing education credits per calendar year.
What you will need:
* Degree: Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, or related field required; equivalent years of work experience in related field will be considered in lieu of degree
* Certification: RHIA, RHIT, CCS-P, CCS, or CPC required. CPMA preferred.
* Experience: 3-5 years of related experience in physician and hospital outpatient medical billing, reimbursement, physician audits, chart review, coding compliance, medical office or patient accounts. 1-2 years' experience working with Senior Physician Management a plus
Other required skills
* The ability to work independently, with little to no supervision
* Strong presentation and communication skills
* The ability to interpret and analyze medical record documentation, encounter forms, and lab reports, Explanation of Benefits, CMS claim forms, third party payor guidelines and government regulations.
* Aptitude for medical terminology, ICD-10, CPT-4, and HCPCS coding systems.
* Demonstrated expertise in multi-specialty evaluation & management (E/M) coding.
* Knowledge of research steps utilized to identify appropriate code selection or billing requirements.
* Proficiency in MS Office's suite of products, including Excel and PowerPoint, and the internet.
* Experience with Epic Billing Systems, including chart review, transaction inquiry, etc.
Benefits:
* Career Pathways to Promote Professional Growth and Development
* Various Medical, Dental, and Vision options
* Tuition Reimbursement
* Free Parking at designated locations
* Wellness Program Savings Plan
* Health Savings Account Options
* Retirement Options with Company Match
* Paid Time Off and Holiday Pay
* Community Involvement Opportunities
Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. Located in Naperville, Linden Oaks Behavioral Health, provides for the mental health needs of area residents. For more information, visit you work for Endeavor Heal
$32.60 - $48.90 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.
Position Highlights:
* Position: Senior Coding Educator
* Location: Skokie, IL
* Full Time
* Hours: Monday-Friday, 8:00am-4:30pm
A Brief Overview:
The purpose of this job is to educate physicians, other qualified billing providers, and ancillary staff on their documentation for all specialties and review providers progress notes, as needed, to ensure coding/billing compliance in accordance with coding rules, third party payor guidelines, governmental regulations, and MG's Coding Compliance Program. The Senior Analyst will conduct face-to-face summary review sessions to report findings to the Practice Manager, Provider audited, and/or Senior Management of the MG. Through the audit/review process, this person will also conduct a report back to the provider and practice manager any income enhancing opportunities that might be uncovered in the investigation. The Senior Analyst, as a coding and billing expert, will assist all freestanding and provider-based outpatient departments with ICD-10, CPT-4, and HCPCS coding education and billing regulation interpretation. They will also assist in conducting department presentations.
What you will do:
* Analyzes progress notes, op reports, pathology reports, encounter forms, explanation of benefits, patient insurance information, and various other health information documents for pro-fee coding and billing accuracy.
* Assigns appropriate ICD-10, CPT, and HCPCS codes to medical record documentation under review by applying physician specialty coding rules, third party payor guidelines, and Medicare Local Medical Review Policies.
* Assists Manager/Director with providing information to the physician or medical specialty based on the Office of Inspector General's (OIG) and Centers for Medicare and Medicaid Services (CMS) risk areas. Reads the OIG's Semi-Annual reports and the OIG'S/CMS's Annual Workplan, in addition to notifications published on government websites.
* Performs physician and departmental documentation reviews based on industry standard coding and billing guidelines and payer policies to provide documentation and workflow improvement opportunities.
* Works with MG physicians or clinic personnel, HIRS, to interpret medical record documentation and/or documentation summary as necessary.
* Works with Customer Service and MG Operations to review and resolve escalated patient coding disputes.
* Works collaboratively with Billing, HIRS, overseeing provider/specialty and Denials Management Team to provide educational and/or income enhancing opportunities when issues are identified by those teams.
* Conducts educational sessions with Site Directors, Practice Managers, and providers on frequently seen coding errors in their site and assists with implementing changes to improve coding quality and minimize compliance risk.
* Provides feedback to Manager/ Director that identifies inefficient coding/operational processes.
* Assists with related special projects as assigned by Manager/ Director.
* Initiate and provide coding education to all MG billing providers, focusing on Evaluation and Management (E&M) documentation and billing requirements, as well as any specialty-specific coding guidelines.
* Works on special projects with the Hospital Billing Business Office and/or the Finance Department to perform reimbursement analysis functions as assigned by Manager/ Director.
* Submits ideas to Manager of Coding Quality & Auditing departmental newsletter based on coding/billing issues, coding help-line questions, or results of provider audits. May produce Monthly Newsletter if assigned.
* Participates in Coding and Business Operation Education in-services assigned by Manager
* Researches multi-specialty coding and billing questions received from the Coding Help-line/email for EHMG provider/staff and provides verbal or written response as appropriate. Maintains filing system of all questions received and answers provided to caller.
* Identifies trends or patterns of questionable coding and billing practices at Hospital Outpatient and Medical Group sites and reports issues to Manager.
* Reports compliance concerns to Manager or compliance hotline according to the Endeavor Healthcare Corporate Compliance Policy/Procedures.
* Develops physician coding tools such as ICD-10 and CPT-4 cheat sheets, coding grids, tip sheets and other educational material for multi-specialty providers to identify appropriate codes or modifiers reimbursed by payers for services performed.
* Assists in the creation of progress note templates per specialty utilizing the CMS documentation regulations or CPT Assistant guidelines as requested by physician's) or assigned by supervisor.
* Attends multi-specialty physician coding, billing, reimbursement seminars to maintain and increase coding, billing, reimbursement expertise/ knowledge.
* Maintains coding credential by obtaining the requiring continuing education credits per calendar year.
What you will need:
* Degree: Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, or related field required; equivalent years of work experience in related field will be considered in lieu of degree
* Certification: RHIA, RHIT, CCS-P, CCS, or CPC required. CPMA preferred.
* Experience: 3-5 years of related experience in physician and hospital outpatient medical billing, reimbursement, physician audits, chart review, coding compliance, medical office or patient accounts. 1-2 years' experience working with Senior Physician Management a plus
Other required skills
* The ability to work independently, with little to no supervision
* Strong presentation and communication skills
* The ability to interpret and analyze medical record documentation, encounter forms, and lab reports, Explanation of Benefits, CMS claim forms, third party payor guidelines and government regulations.
* Aptitude for medical terminology, ICD-10, CPT-4, and HCPCS coding systems.
* Demonstrated expertise in multi-specialty evaluation & management (E/M) coding.
* Knowledge of research steps utilized to identify appropriate code selection or billing requirements.
* Proficiency in MS Office's suite of products, including Excel and PowerPoint, and the internet.
* Experience with Epic Billing Systems, including chart review, transaction inquiry, etc.
Benefits:
* Career Pathways to Promote Professional Growth and Development
* Various Medical, Dental, and Vision options
* Tuition Reimbursement
* Free Parking at designated locations
* Wellness Program Savings Plan
* Health Savings Account Options
* Retirement Options with Company Match
* Paid Time Off and Holiday Pay
* Community Involvement Opportunities
Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. Located in Naperville, Linden Oaks Behavioral Health, provides for the mental health needs of area residents. For more information, visit you work for Endeavor Heal
Not Specified
D
staff - Registered Nurse (RN) - Case Management - $31-42 per hour
✦ New
Salary not disclosed
Detroit Medical Center is seeking a Registered Nurse (RN) Case Management for a nursing job in Detroit, Michigan.
Job Description & Requirements Specialty: Case Management Discipline: RN Duration: Ongoing 36 hours per week Shift: 12 hours Employment Type: Staff Are you a results-driven leader ready to make a meaningful impact to patients, caregivers, and your community? At DMC Detroit Receiving Hospital , we're seeking an innovative and experienced healthcare leader to drive excellence and inspire our team towards exceptional patient outcomes and operational success.
Benefits Statement At Tenet Healthcare, we understand that our greatest asset is our dedicated team of professionals.
That's why we offer more than a job
- we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance.
The available plans and programs include:
- Medical, dental, vision, and life insurance
- 401(k) retirement savings plan with employer match
- Generous paid time off (PTO)
- Career development and continuing education opportunities
- Health savings accounts, healthcare & dependent flexible spending accounts
- Employee Assistance program, Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.
Note: Eligibility for benefits may vary by location and is determined by employment status Summary Description Oversees hospital utilization performance improvement and operational management of the site Case Management Department to promote effective utilization of hospital resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughput, and ensure compliance with all state and federal regulations related to case management services.
Integrates national standards for case management scope of services including:
- Utilization Management supporting medical necessity and denial prevention
- Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
- Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
- Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
- Education provided to physicians, patients, families, and caregivers Responsibilities include the following activities: a) manages department operations to assure effective throughput and reimbursement for services provided, b) leads the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement, c) ensures medical necessity review processes are completed accurately and in compliance with CMS regulations and Tenet policy, d) ensures timely and effective patient transition and planning to support efficient patient throughput, e) implements and monitors processes to prevent payer disputes, f) develops and provides physician education and feedback on hospital utilization, g) ensures compliance with state and federal regulations and TJC accreditation standards, and h) other duties as assigned.
Drafts policy provisions and provides interpretation of department policies, in accordance with the DMC Utilization Review Plan.
Identifies the need for and drafts or defines procedures/protocols in collaboration with higher management input, goals, and objectives; modifies procedures/protocols, as necessary.
Monitors the quality and productivity of staff to ensure work is completed.
Implements performance improvement activities to insure consistency and safety within departmental activities.
Initiates or recommends personnel actions such as hires, fires, disciplines, etc.
Completes performance appraisals and ensures competency of staff.
Assists in the development of daily, monthly, and/or yearly goals and measures for department, and as requested, assists in assessment of goal attainment.
Assists in developing and monitoring budget.
Monitors activities for and ensures compliance with laws, government regulations, Joint Commission requirements and DMC policies relating to areas of responsibility.
As directed, implements external and internal audit recommendations.
POSITION SPECIFIC RESPONSIBILITIES: Department Operations
- Maintains an adequate number and skill mix over seven days a week to serve the patient population and meet the goals of the department
- Implements and supports with business case staffing requests utilizing the Tenet Case Management staffing recommendations and hospital budgetary guidelines
- Holds regular departmental meetings with staff to provide updates and provides for ongoing education
- Completes initial and annual competency and evaluation review on all case management staff
- Follows the InterQual Inter-rater Reliability (IRR) Policy to determine initial and yearly competency for all employees performing InterQual reviews
- Develops action plan for case managers that fail to meet the IRR acceptable "match" rate to ensure improvement in the accurate application of InterQual criteria
- Ensures new case management staff complete department orientation including review of Tenet Case Management and Compliance policies and Allscripts training.
- Monitors case management processes and staff productivity to ensure medical necessity reviews are completed timely and accurately, payer communications are sent, and authorizations or denials documented and followed up, and that transition planning assessments are completed timely.
Utilization Management Implements and monitors processes to ensure medical necessity review processes are in place for patients to be in the appropriate status and level of care per Tenet policy.
Oversees submission of cases to Physician Advisor review to ensure timely referral, follow up and documentation.
Implements and monitors utilization review process in place to communicate appropriate clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services.
- Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
- Participates in Revenue Cycle meeting, researching disputes, uncovering patterns/trends, and educating hospital and medical staff on actionable items
- Implements and monitors physician "peer to peer" review process with payers to resolve denials or downgrades concurrently.
- Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
- Monitors, analyzes, and reports Avoidable Days using the data to address opportunities for improvement
- Participates and/or serves as lead for hospital Medicare Performance Improvement (MPI) initiatives.
- Utilizes Crimson data to provide timely and meaningful information to the Utilization Management Committee and physician staff for performance improvement.
- Monitors to ensure that CMS Follow-up Important Message (IM) and HINN letters are delivered and documented per federal regulations and Tenet policy.
Transition Management
- Implements and monitors process to ensure that a transition plan assessment is completed within 24 hours of patient admission to identify and document the anticipated transition plan for patients
- Ensures case management staff use electronic referral request process for patient placements
- Monitors to ensure that patient choice is documented per CMS regulations and Tenet policy
- Identifies and reports variances in appropriateness of medical care provided over/under utilization of resources compared to evidence-based practice and external requirements.
- Monitors to ensure case management staff document in the Tenet Case Management system to communicating information through clear, complete, and concise documentation Care Coordination
- Works with Nursing and hospital leadership to ensure Patient Care Conferences and Complex Case Review processes are in place to promote timely and appropriate throughput
- Participates in daily bed management meeting to support timely and effective patient placement and transfer within the hospital
- Monitors to ensures that patients have a plan of care that is clinically appropriate, consistent with patient choice and available resources
- Monitors to ensures consults, testing and procedures are sequenced to support clinical needs with timely and efficient care delivery
- Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
- Effectively collaborates with physicians, nurses, ancillary staff, payors, patients, and families to achieve optimum clinical outcomes Education
- Provides education to physicians regarding medical necessity, complete and accurate documentation, and compliance with related regulatory requirements
- Prepares and provides data to physicians and the hospital on utilization of resources
- Provides education to case management staff, physicians, and the healthcare team relevant to the o Effective progression of care, o Appropriate level of care, and o Safe and timely patient transition Compliance
- Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
- Ensures that the department structure and staffing, policies, and procedures to comply with the CMS Conditions of Participation and Tenet policies
- Operates within the RN scope of practice as defined by state licensing regulations
- Implements and monitors compliance with Tenet Case Management practices Qualifications: Minimum Qualifications 1.
Bachelor's degree in Nursing or other health-related field, or the equivalent combination of education and/or related experience or Master's in Social Work for MSW.
Master's degree in Nursing, Business Administration or Hospital Administration preferred.
2.
Registered Nurse or LCSW/LMSW license.
Must be currently licensed, certified, or registered to practice profession as required by law or regulation in state of practice or policy.
Active RN or LCSW/LMSW license for state(s) covered.
3.
Three to five years of acute hospital case management leadership experience.
Five years acute hospital case management experience preferred.
McKesson InterQual® experience preferred.
Business planning experience preferred.
4.
Accredited Case Manager (ACM) preferred.
Skills Required 1.
Analytical ability to serve in an advisory/consultative role in determining and/or developing strategies, policies, processes, protocols and methods, frequently in the absence of guidelines or technical assistance, and to evaluate and direct complex systems that foster innovative approaches to procedures/processes.
2.
Fiscal skills to monitor and control costs and revenue.
3.
Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously.
4.
Strong communication and interpersonal skills for frequent contacts with internal customers as well as stakeholders external to the DMC to persuade or negotiate on a wide range of subjects in situations which may be controversial, sensitive and/or lead to confrontation.
A mastery of a variety of communication modalities is required to include leading meetings, making formal presentations, and writing complex documents and managing complex relationships over time.
5.
Teaching abilities to conduct educational programs for staff.
6.
Project management skills including the ability to define program, project, or process objectives, identify stakeholders and their interests, plan steps, coordinate and allocate human, technological and fiscal resources to accomplish goals and objectives in a resourceful yet timely manner.
7.
Leadership skills including demonstrated willingness to pursue leadership roles with increasing levels of accountability, comfort with decision-making responsibilities, coaching, teaching and counseling skills, and the ability to inspire and build confidence in others and to forge alliances and garner support.
8.
Technical knowledge of community resources, regulatory requirements, reimbursements, and utilization management procedures in order to function Facility Description DMC Detroit Receiving Hospital, Michigan's first Level I Trauma Center, helped pioneer the evolution of emergency medicine and currently has one of the busiest and most well-equipped emergency departments anywhere.
The first and largest verified burn center in the state is at Receiving, and it is one of only 43 in the nation.
Receiving also offers the state's leading 24/7 hyperbaric oxygen program, Metro Detroit's first certified primary stroke center, and the nationally recognized and accredited DMC Rosa Parks Geriatric Center of Excellence.
EEO Statement: Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status.
Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet participates in the E-Verify program.
Follow the link below for additional information.
E-Verify: employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.
Job: Case Management Primary Location: Detroit, Michigan Facility: DMC Receiving Hospital Job Type: Full Time Shift Type: Day Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status.
Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet participates in the E-Verify program.
Follow the link below for additional information.
E-Verify: /> The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.
Detroit Medical Center Job ID 43690.
Posted job title: Director
- Case Management About Detroit Medical Center The Detroit Medical Center (DMC) is the leading academically-integrated hospital system in Metro Detroit, and one of the largest health care providers in Southeast Michigan.
During our 150 years of caring for the community, we have been recognized nationally with top awards in many aspects of hospital operations and patient care.
The DMC is able to achieve these awards because of our exceptional employees.
The Detroit Medical Center is one the largest academic medical centers in the United States, with a long and rich history of medical education, for more than 100 years.
We train more physicians than any other hospital in Detroit.
Our evidence-based approach inspires confidence and spurs innovation.
It ensures that we are making treatment decisions based on our experience, on the best available research and our understanding of each patient as an individual.
Our commitment to our patients Our commitment to patient care and improving patient outcomes is part of everything we do.
It's our mission.
It's our promise to every patient and every family who entrusts their care to us.
To meet the needs of our community, we operate 8 hospitals and more than 140 clinics and outpatient facilities across southeast Michigan, including a nationally recognized dedicated pediatric hospital (Children's Hospital of Michigan) as well as a nationally recognized rehabilitation hospital (Rehabilitation Institute of Michigan).
We offer an inclusive, diverse and supportive environment.
Knowing that we are better together, our teams are highly collaborative and integrated to deliver the high quality and compassionate care our patients expect and deserve.
Staff members have a voice in forming our culture; one that is often referred to as "my forever family" and "colleagues who have my back".
The DMC has a proud legacy of caring for the people and the families that call Metro Detroit home; they're our neighbors, our friends, and our community.
That's why the DMC serves everyone in the community who needs us; no one gets turned away who comes to us for care.
From local food drives to our long-standing commitment to educate and empower our community towards better health, you can count on the DMC.
There's a spirit of caring and togetherness that you will experience when you join the DMC family.
We are a community build on care.
At the DMC, we are committed to maintaining an environment of Equal Opportunity and Affirmative Action.
If you need a reasonable accommodation to access the information provided on this web site, please contact the DMC facility where the position is available, for further assistance.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran status or status as an individual disability.
Employee Benefits At the DMC, health and well-being are important to us, so we provide a range of benefits and options to help meet the needs of all eligible employees.
In addition to a range of healthcare plans, including higher and lower deductible options, we offer dental, vision and an employee assistance plan.
Basic life insurance and Accidental Death and Dismemberment insurance are provided for free to eligible plan members.
Employees can also choose to participate in one of several supplemental life insurance and/or disability plans, a legal services plan and an identity protection plan.
For those employees who are looking for support to care for family members, we also offer child and elder care programs.
To help employees prepare for retirement, we offer a 401K savings plan, and an employee discount plan that includes discounts for a wide variety of products, including auto and home insurance and mobile plans.
Benefits Medical benefits Dental benefits Vision benefits Employee assistance programs Life insurance Discount program5c143e31-5e48-4549-b638-05792d185386
Job Description & Requirements Specialty: Case Management Discipline: RN Duration: Ongoing 36 hours per week Shift: 12 hours Employment Type: Staff Are you a results-driven leader ready to make a meaningful impact to patients, caregivers, and your community? At DMC Detroit Receiving Hospital , we're seeking an innovative and experienced healthcare leader to drive excellence and inspire our team towards exceptional patient outcomes and operational success.
Benefits Statement At Tenet Healthcare, we understand that our greatest asset is our dedicated team of professionals.
That's why we offer more than a job
- we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance.
The available plans and programs include:
- Medical, dental, vision, and life insurance
- 401(k) retirement savings plan with employer match
- Generous paid time off (PTO)
- Career development and continuing education opportunities
- Health savings accounts, healthcare & dependent flexible spending accounts
- Employee Assistance program, Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.
Note: Eligibility for benefits may vary by location and is determined by employment status Summary Description Oversees hospital utilization performance improvement and operational management of the site Case Management Department to promote effective utilization of hospital resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughput, and ensure compliance with all state and federal regulations related to case management services.
Integrates national standards for case management scope of services including:
- Utilization Management supporting medical necessity and denial prevention
- Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
- Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
- Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
- Education provided to physicians, patients, families, and caregivers Responsibilities include the following activities: a) manages department operations to assure effective throughput and reimbursement for services provided, b) leads the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement, c) ensures medical necessity review processes are completed accurately and in compliance with CMS regulations and Tenet policy, d) ensures timely and effective patient transition and planning to support efficient patient throughput, e) implements and monitors processes to prevent payer disputes, f) develops and provides physician education and feedback on hospital utilization, g) ensures compliance with state and federal regulations and TJC accreditation standards, and h) other duties as assigned.
Drafts policy provisions and provides interpretation of department policies, in accordance with the DMC Utilization Review Plan.
Identifies the need for and drafts or defines procedures/protocols in collaboration with higher management input, goals, and objectives; modifies procedures/protocols, as necessary.
Monitors the quality and productivity of staff to ensure work is completed.
Implements performance improvement activities to insure consistency and safety within departmental activities.
Initiates or recommends personnel actions such as hires, fires, disciplines, etc.
Completes performance appraisals and ensures competency of staff.
Assists in the development of daily, monthly, and/or yearly goals and measures for department, and as requested, assists in assessment of goal attainment.
Assists in developing and monitoring budget.
Monitors activities for and ensures compliance with laws, government regulations, Joint Commission requirements and DMC policies relating to areas of responsibility.
As directed, implements external and internal audit recommendations.
POSITION SPECIFIC RESPONSIBILITIES: Department Operations
- Maintains an adequate number and skill mix over seven days a week to serve the patient population and meet the goals of the department
- Implements and supports with business case staffing requests utilizing the Tenet Case Management staffing recommendations and hospital budgetary guidelines
- Holds regular departmental meetings with staff to provide updates and provides for ongoing education
- Completes initial and annual competency and evaluation review on all case management staff
- Follows the InterQual Inter-rater Reliability (IRR) Policy to determine initial and yearly competency for all employees performing InterQual reviews
- Develops action plan for case managers that fail to meet the IRR acceptable "match" rate to ensure improvement in the accurate application of InterQual criteria
- Ensures new case management staff complete department orientation including review of Tenet Case Management and Compliance policies and Allscripts training.
- Monitors case management processes and staff productivity to ensure medical necessity reviews are completed timely and accurately, payer communications are sent, and authorizations or denials documented and followed up, and that transition planning assessments are completed timely.
Utilization Management Implements and monitors processes to ensure medical necessity review processes are in place for patients to be in the appropriate status and level of care per Tenet policy.
Oversees submission of cases to Physician Advisor review to ensure timely referral, follow up and documentation.
Implements and monitors utilization review process in place to communicate appropriate clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services.
- Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
- Participates in Revenue Cycle meeting, researching disputes, uncovering patterns/trends, and educating hospital and medical staff on actionable items
- Implements and monitors physician "peer to peer" review process with payers to resolve denials or downgrades concurrently.
- Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
- Monitors, analyzes, and reports Avoidable Days using the data to address opportunities for improvement
- Participates and/or serves as lead for hospital Medicare Performance Improvement (MPI) initiatives.
- Utilizes Crimson data to provide timely and meaningful information to the Utilization Management Committee and physician staff for performance improvement.
- Monitors to ensure that CMS Follow-up Important Message (IM) and HINN letters are delivered and documented per federal regulations and Tenet policy.
Transition Management
- Implements and monitors process to ensure that a transition plan assessment is completed within 24 hours of patient admission to identify and document the anticipated transition plan for patients
- Ensures case management staff use electronic referral request process for patient placements
- Monitors to ensure that patient choice is documented per CMS regulations and Tenet policy
- Identifies and reports variances in appropriateness of medical care provided over/under utilization of resources compared to evidence-based practice and external requirements.
- Monitors to ensure case management staff document in the Tenet Case Management system to communicating information through clear, complete, and concise documentation Care Coordination
- Works with Nursing and hospital leadership to ensure Patient Care Conferences and Complex Case Review processes are in place to promote timely and appropriate throughput
- Participates in daily bed management meeting to support timely and effective patient placement and transfer within the hospital
- Monitors to ensures that patients have a plan of care that is clinically appropriate, consistent with patient choice and available resources
- Monitors to ensures consults, testing and procedures are sequenced to support clinical needs with timely and efficient care delivery
- Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
- Effectively collaborates with physicians, nurses, ancillary staff, payors, patients, and families to achieve optimum clinical outcomes Education
- Provides education to physicians regarding medical necessity, complete and accurate documentation, and compliance with related regulatory requirements
- Prepares and provides data to physicians and the hospital on utilization of resources
- Provides education to case management staff, physicians, and the healthcare team relevant to the o Effective progression of care, o Appropriate level of care, and o Safe and timely patient transition Compliance
- Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
- Ensures that the department structure and staffing, policies, and procedures to comply with the CMS Conditions of Participation and Tenet policies
- Operates within the RN scope of practice as defined by state licensing regulations
- Implements and monitors compliance with Tenet Case Management practices Qualifications: Minimum Qualifications 1.
Bachelor's degree in Nursing or other health-related field, or the equivalent combination of education and/or related experience or Master's in Social Work for MSW.
Master's degree in Nursing, Business Administration or Hospital Administration preferred.
2.
Registered Nurse or LCSW/LMSW license.
Must be currently licensed, certified, or registered to practice profession as required by law or regulation in state of practice or policy.
Active RN or LCSW/LMSW license for state(s) covered.
3.
Three to five years of acute hospital case management leadership experience.
Five years acute hospital case management experience preferred.
McKesson InterQual® experience preferred.
Business planning experience preferred.
4.
Accredited Case Manager (ACM) preferred.
Skills Required 1.
Analytical ability to serve in an advisory/consultative role in determining and/or developing strategies, policies, processes, protocols and methods, frequently in the absence of guidelines or technical assistance, and to evaluate and direct complex systems that foster innovative approaches to procedures/processes.
2.
Fiscal skills to monitor and control costs and revenue.
3.
Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously.
4.
Strong communication and interpersonal skills for frequent contacts with internal customers as well as stakeholders external to the DMC to persuade or negotiate on a wide range of subjects in situations which may be controversial, sensitive and/or lead to confrontation.
A mastery of a variety of communication modalities is required to include leading meetings, making formal presentations, and writing complex documents and managing complex relationships over time.
5.
Teaching abilities to conduct educational programs for staff.
6.
Project management skills including the ability to define program, project, or process objectives, identify stakeholders and their interests, plan steps, coordinate and allocate human, technological and fiscal resources to accomplish goals and objectives in a resourceful yet timely manner.
7.
Leadership skills including demonstrated willingness to pursue leadership roles with increasing levels of accountability, comfort with decision-making responsibilities, coaching, teaching and counseling skills, and the ability to inspire and build confidence in others and to forge alliances and garner support.
8.
Technical knowledge of community resources, regulatory requirements, reimbursements, and utilization management procedures in order to function Facility Description DMC Detroit Receiving Hospital, Michigan's first Level I Trauma Center, helped pioneer the evolution of emergency medicine and currently has one of the busiest and most well-equipped emergency departments anywhere.
The first and largest verified burn center in the state is at Receiving, and it is one of only 43 in the nation.
Receiving also offers the state's leading 24/7 hyperbaric oxygen program, Metro Detroit's first certified primary stroke center, and the nationally recognized and accredited DMC Rosa Parks Geriatric Center of Excellence.
EEO Statement: Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status.
Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet participates in the E-Verify program.
Follow the link below for additional information.
E-Verify: employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.
Job: Case Management Primary Location: Detroit, Michigan Facility: DMC Receiving Hospital Job Type: Full Time Shift Type: Day Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status.
Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet participates in the E-Verify program.
Follow the link below for additional information.
E-Verify: /> The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.
Detroit Medical Center Job ID 43690.
Posted job title: Director
- Case Management About Detroit Medical Center The Detroit Medical Center (DMC) is the leading academically-integrated hospital system in Metro Detroit, and one of the largest health care providers in Southeast Michigan.
During our 150 years of caring for the community, we have been recognized nationally with top awards in many aspects of hospital operations and patient care.
The DMC is able to achieve these awards because of our exceptional employees.
The Detroit Medical Center is one the largest academic medical centers in the United States, with a long and rich history of medical education, for more than 100 years.
We train more physicians than any other hospital in Detroit.
Our evidence-based approach inspires confidence and spurs innovation.
It ensures that we are making treatment decisions based on our experience, on the best available research and our understanding of each patient as an individual.
Our commitment to our patients Our commitment to patient care and improving patient outcomes is part of everything we do.
It's our mission.
It's our promise to every patient and every family who entrusts their care to us.
To meet the needs of our community, we operate 8 hospitals and more than 140 clinics and outpatient facilities across southeast Michigan, including a nationally recognized dedicated pediatric hospital (Children's Hospital of Michigan) as well as a nationally recognized rehabilitation hospital (Rehabilitation Institute of Michigan).
We offer an inclusive, diverse and supportive environment.
Knowing that we are better together, our teams are highly collaborative and integrated to deliver the high quality and compassionate care our patients expect and deserve.
Staff members have a voice in forming our culture; one that is often referred to as "my forever family" and "colleagues who have my back".
The DMC has a proud legacy of caring for the people and the families that call Metro Detroit home; they're our neighbors, our friends, and our community.
That's why the DMC serves everyone in the community who needs us; no one gets turned away who comes to us for care.
From local food drives to our long-standing commitment to educate and empower our community towards better health, you can count on the DMC.
There's a spirit of caring and togetherness that you will experience when you join the DMC family.
We are a community build on care.
At the DMC, we are committed to maintaining an environment of Equal Opportunity and Affirmative Action.
If you need a reasonable accommodation to access the information provided on this web site, please contact the DMC facility where the position is available, for further assistance.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran status or status as an individual disability.
Employee Benefits At the DMC, health and well-being are important to us, so we provide a range of benefits and options to help meet the needs of all eligible employees.
In addition to a range of healthcare plans, including higher and lower deductible options, we offer dental, vision and an employee assistance plan.
Basic life insurance and Accidental Death and Dismemberment insurance are provided for free to eligible plan members.
Employees can also choose to participate in one of several supplemental life insurance and/or disability plans, a legal services plan and an identity protection plan.
For those employees who are looking for support to care for family members, we also offer child and elder care programs.
To help employees prepare for retirement, we offer a 401K savings plan, and an employee discount plan that includes discounts for a wide variety of products, including auto and home insurance and mobile plans.
Benefits Medical benefits Dental benefits Vision benefits Employee assistance programs Life insurance Discount program5c143e31-5e48-4549-b638-05792d185386
Not Specified
Medical Staff Services & Credentialing Supervisor
Salary not disclosed
POSITION SUMMARY
The Medical Staff Services & Credentialing Supervisor is responsible for the day-to-day operational supervision, oversight, and performance management of the Medical Staff Office credentialing team and administrative support functions. This role ensures that all medical staff credentialing, privileging, reappointment, and related Medical Staff processes are executed in full compliance with The Joint Commission (TJC), CMS, Medicaid, NCQA, Medical Staff Bylaws, and organizational policies.
In addition, the Supervisor serves as a key operational partner to the Senior Director of Physician Services and the Delegation Analyst to ensure alignment, accountability, and consistency across credentialing and delegated credentialing functions. While the Supervisor does not own delegation work as a primary responsibility, they are expected to collaborate, escalate issues, support operational problem-solving, and provide leadership coverage as needed, including stepping in alongside the Senior Director when required to support continuity of operations.
This role functions as a representative of the Medical Staff Office in internal and external interactions and serves as the final internal operational review for credentialing and privileging items prior to presentation to the Credentials Committee, Medical Executive Committee (MEC), and other governing bodies.
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES
Medical Staff Credentialing & Privileging Oversight
Delegated Credentialing Collaboration & Oversight
Supervisory & Leadership Responsibilities
Committee & Governance Support
Systems, Data Integrity & Reporting
Regulatory, Accreditation & Survey Readiness
Representation & Professional Collaboration
Decision-Making Authority
QUALIFICATIONS
Required
Preferred
KNOWLEDGE AND SKILLS:
Core Competencies
PERFORMANCE EXPECTATIONS
WORK ENVIRONMENT
Work Location: On-site; travel between campuses and other locations required as needed
The above statement reflects the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.
Total Rewards at AtlantiCare
At AtlantiCare, we believe in supporting the whole person. Our market-competitive Total Rewards package is designed to promote the physical, emotional, social, and financial well-being of our team members. We offer a comprehensive suite of benefits and resources, including:
Generous Paid Time Off (PTO)
Medical, Prescription Drug, Dental & Vision Insurance
Retirement Plans with employer contributions
Short-Term & Long-Term Disability Coverage
Life & Accidental Death & Dismemberment Insurance
Tuition Reimbursement to support your educational goals
Flexible Spending Accounts (FSAs) for healthcare and dependent care
Wellness Programs to help you thrive
Voluntary Benefits, including Pet Insurance and more
Benefits offerings may vary based on position and are subject to eligibility requirements.
Join a team that values your well-being and invests in your future.
The Medical Staff Services & Credentialing Supervisor is responsible for the day-to-day operational supervision, oversight, and performance management of the Medical Staff Office credentialing team and administrative support functions. This role ensures that all medical staff credentialing, privileging, reappointment, and related Medical Staff processes are executed in full compliance with The Joint Commission (TJC), CMS, Medicaid, NCQA, Medical Staff Bylaws, and organizational policies.
In addition, the Supervisor serves as a key operational partner to the Senior Director of Physician Services and the Delegation Analyst to ensure alignment, accountability, and consistency across credentialing and delegated credentialing functions. While the Supervisor does not own delegation work as a primary responsibility, they are expected to collaborate, escalate issues, support operational problem-solving, and provide leadership coverage as needed, including stepping in alongside the Senior Director when required to support continuity of operations.
This role functions as a representative of the Medical Staff Office in internal and external interactions and serves as the final internal operational review for credentialing and privileging items prior to presentation to the Credentials Committee, Medical Executive Committee (MEC), and other governing bodies.
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES
Medical Staff Credentialing & Privileging Oversight
- Provide direct supervision and operational leadership to Credentialing Specialists and Administrative Secretary.
- Ensure timely, accurate, and compliant processing of:
- Initial appointments
- Reappointments
- Privilege requests and modifications
- Resignations, leaves of absence, suspensions, and reinstatements
- Confirm adherence to:
- Medical Staff Bylaws, Rules & Regulations, and policies
- Credentialing and privileging criteria
- Regulatory and accreditation standards (TJC, CMS, Medicaid, NCQA)
- Serve as the final internal operational review prior to submission to:
- Credentials Committee
- Medical Executive Committee (MEC)
- Governing Board, as applicable
Delegated Credentialing Collaboration & Oversight
- Collaborate closely with the Delegation Analyst and Senior Director to ensure:
- Credentialing Specialists understand and meet expectations related to delegated credentialing workflows.
- Credentialing processes align with NCQA delegated credentialing requirements and payor expectations.
- Serve as an escalation and coordination point when issues arise that impact credentialing accuracy, timeliness, or delegation readiness.
- Support cross-functional problem-solving related to:
- Data integrity
- File completeness
- Audit findings
- Process gaps affecting delegation
- Maintain flexibility to assist or step in alongside the Senior Director as needed to support delegation-related initiatives or operational continuity.
Supervisory & Leadership Responsibilities
- Assign, prioritize, and monitor daily and long-term work assignments for credentialing staff.
- Conduct ongoing performance coaching, feedback, and corrective guidance in collaboration with the Senior Director.
- Participate in performance evaluations and staff development planning.
- Approve staff PTO requests in coordination with the Senior Director; ensure appropriate coverage and continuity of operations.
- Monitor workload distribution and proactively identify staffing or workflow concerns.
- Ensure staff compliance with departmental standards, timelines, and expectations.
- Serve as a role model for professionalism, accountability, and regulatory rigor.
Committee & Governance Support
- Ensure credentialing and privileging materials are:
- Accurate
- Complete
- Properly vetted
- Submitted in accordance with established deadlines
- Support preparation of agendas, supporting documentation, and follow-up actions for:
- Credentials Committee
- Medical Executive Committee (MEC)
- Other Medical Staff or governance committees as assigned
- Track and ensure timely execution of committee decisions and follow-up actions.
Systems, Data Integrity & Reporting
- Oversee accurate data entry and maintenance within MSOW (current system).
- Play a key operational role in the transition from MSOW to MD-Staff, including:
- Staff readiness
- Workflow alignment
- Data accuracy and consistency
- Ensure credentialing data integrity to support:
- Master Roster development
- Regulatory reporting
- Payor and delegated credentialing requirements
- Identify trends, risks, and process gaps and escalate concerns to the Senior Director.
Regulatory, Accreditation & Survey Readiness
- Maintain continuous readiness for:
- TJC surveys
- CMS and Medicaid reviews
- NCQA accreditation and delegated credentialing audits
- Ensure documentation, files, and workflows meet surveyor expectations.
- Participate in surveys, audits, and site visits as required, including travel between campuses or other locations.
Representation & Professional Collaboration
- Represent the Medical Staff Office in meetings with:
- Physicians and APPs
- Department Chairs and Medical Staff leadership
- Quality, HR, IT, Compliance, and other departments
- Communicate professionally and effectively with internal and external stakeholders.
- Escalate sensitive or high-risk issues to the Senior Director in a timely manner.
Decision-Making Authority
- Authorized to make day-to-day operational decisions related to credentialing workflow, staff assignments, and issue resolution.
- May approve PTO in coordination with the Senior Director.
- May represent the Medical Staff Office operationally in meetings and discussions.
- Does not independently alter Medical Staff policy, bylaws, or credentialing criteria without Senior Director approval.
QUALIFICATIONS
Required
- Bachelor's degree or equivalent combination of education and experience preferred.
- Progressive experience in medical staff credentialing or provider enrollment.
- Prior supervisory or lead experience strongly preferred.
- Demonstrated working knowledge of:
- Medical Staff Bylaws and governance
- Credentialing and privileging standards
- TJC, CMS, Medicaid, and NCQA requirements
- Experience using credentialing systems (MSOW and/or MD-Staff preferred).
Preferred
- Experience supporting delegated credentialing or NCQA accreditation.
- Experience in a multi-hospital or complex health system environment.
KNOWLEDGE AND SKILLS:
Core Competencies
- Regulatory and accreditation expertise
- Operational leadership and staff supervision
- Attention to detail and risk awareness
- Professional judgment and discretion
- Strong written and verbal communication
- Ability to manage competing priorities and deadlines
- Collaboration and escalation judgment
PERFORMANCE EXPECTATIONS
WORK ENVIRONMENT
Work Location: On-site; travel between campuses and other locations required as needed
The above statement reflects the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.
Total Rewards at AtlantiCare
At AtlantiCare, we believe in supporting the whole person. Our market-competitive Total Rewards package is designed to promote the physical, emotional, social, and financial well-being of our team members. We offer a comprehensive suite of benefits and resources, including:
Generous Paid Time Off (PTO)
Medical, Prescription Drug, Dental & Vision Insurance
Retirement Plans with employer contributions
Short-Term & Long-Term Disability Coverage
Life & Accidental Death & Dismemberment Insurance
Tuition Reimbursement to support your educational goals
Flexible Spending Accounts (FSAs) for healthcare and dependent care
Wellness Programs to help you thrive
Voluntary Benefits, including Pet Insurance and more
Benefits offerings may vary based on position and are subject to eligibility requirements.
Join a team that values your well-being and invests in your future.
Not Specified
N
MSO Claims Manager
Salary not disclosed
The Claims Manager is responsible for overseeing the end-to-end claims operations within the MSO managed care delegated functions. This role provides guidance on healthcare claims adjudication and payment processing for Medi-Cal, Medicare, PACE, and other lines of business based on member Evidence of Coverages (EOC) and CMS/DHCS guidelines, ensures that claims are processed accurately, timely, and in compliance with regulatory requirements and contractual obligations. The Claims Manager will lead the claims team, implement process improvements, and collaborate with internal and external stakeholders to optimize claims adjudication workflows.
This role requires high-level of decision-making and problem-solving skills in relates to claims operations, compliance, and process improvements. Deep understanding of Medi-Cal, Medicare Advantage, PACE, CMS, and DHCS regulations; ensuring full compliance across the department. Ability to manage multiple priorities, oversee department workflows, and optimize resource allocation. Responsible to design training programs for claims teams and leads initiatives to enhance team expertise. Excellent communication skills to interact with leadership, payers, providers, auditors, and MSO internal departments.
ESSENTIAL JOB FUNCTIONS:
- Oversee managed care claims processing, ensuring compliance with CMS, DHCS, and health plan guidelines.
- Monitor claims adjudication, ensuring accuracy, timeliness, and regulatory adherence.
- Develop and implement policies and procedures to improve claims processing efficiency.
- Work with IT and system vendors to optimize claims processing systems and troubleshoot issues.
- Lead and mentor the claims team, including Claims Supervisors and processors, ensuring high performance and engagement.
- Conduct regular performance evaluations, design training programs, provide training, and develop staff competencies.
- Establish and monitor productivity metrics to enhance team efficiency.
- Serve as the primary liaison with health plans, providers, auditors, and third-party administrators to resolve claims issues and disputes.
- Manage escalations, appeals, and grievances related to claims processing.
- Coordinate with provider relations to address claims denials and payment disputes.
- Identify areas for process improvement and implement best practices to enhance claims adjudication.
- Analyze claims data, trends, and key performance indicators to drive operational enhancements.
- Prepare reports for senior management on claims performance, backlog, and issue resolution.
- Direct supervision of a department involving responsibility for results in terms of costs, methods and personnel. Responsible for carrying out supervisory/managerial responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing and hiring of employees; planning, assigning, scheduling, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
- Performs other job duties as required by manager/supervisor.
QUALIFICATIONS:
- Bachelor's degree in business, healthcare administration, or related field is preferred; Associate’s degree may be considered with relevant, equivalent work experience.
- Experience: Minimum of 5 years in managed care claims and compliance field, with at least 3 years in a managerial role within an IPA, health plan, medical group, or TPA.
- Knowledge of: Medi-Cal and MA claims processing, CMS and DHCS regulations, capitated vs. fee-for-service (FFS) models, claims adjudication systems (e.g., EZ-CAP, HealthEdge, Tapestry, or similar).
- Skills: Strong analytical, problem-solving, and leadership skills. Proficiency in Excel, reporting tools, and claims systems.
- Certifications (Preferred): AAHAM, CPC, or other relevant claims-related certifications.
LANGUAGE:
- Must be able to fluently speak, read and write English.
- Fluency in other languages are an asset.
STATUS:
- This is an FLSA Exempt position.
- This is not an OSHA high-risk position.
- This is a full-time position.
NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).
Not Specified
Patient Relations Consultant
✦ New
Salary not disclosed
Cambridge Health Alliance (CHA)'s Division of Quality is responsible for promoting a culture of safety, patient and staff engagement, and performance excellence aligned with national patient safety goals.
The Patient Relations Consultant plays a critical role within CHA, serving a diverse patient population as a liaison between patients, their families, and healthcare teams to ensure concerns are addressed and patient perspectives inform improvement. The consultant serves as a patient advocate, facilitating the resolution of concerns and mediating communication between patients, families, and care teams, while elevating patient feedback to strengthen a culture of safety, reliability, and patient-centered care.
Position Overview
This position is responsible for managing complaints, Human Rights inquiries, and Quality of Care complaints in accordance with CMS and DMH guidelines. In addition to resolution of individual concerns, the consultant identifies patterns and themes in patient feedback and partners with clinical and operational leaders to facilitate service recovery, promote learning, and support improvement efforts.
Working closely with the Director of Patient Experience and partners across Quality and Safety—including Risk Management, Performance Improvement, and the Quality & Safety Data and Analytics teams—the Patient Relations Consultant contributes to CHA’s High Reliability journey by ensuring the patient voice informs organizational learning, service recovery, and improvement efforts, while supporting regulatory readiness and compliance.
Key Responsibilities
- Complaint Management: Timely investigation, resolution, and response to all patient concerns, complaints, and grievances in adherence to CMS guidelines.
- Service Recovery: Collaborate with leadership to identify and implement service recovery opportunities to ensure exceptional patient/family experience outcomes. Rounding in Med Surg Units to provide Service Recovery coaching as needed.
- Patient Advocacy: Act as a patient advocate, ensuring patient and human rights are respected and their voices are heard throughout their care journey.
- Documentation and Reporting: Maintain meticulous records of complaints, investigations, and resolutions, contributing to data-driven decision-making for patient experience improvement.
- Cultural Competency: Contribute to building patient experience programs that align with and support cultural competency, diversity, equity, and inclusion efforts.
- Collaboration: Partner with various departments and frontline staff to understand patient needs and concerns, and to promote a shared vision for service excellence.
- Elevate the Patient Voice: Ensure patient feedback is meaningfully represented in organizational learning by sharing themes, insights, and direct patient perspectives in the Grievance Committee and other governance forums.
- Organizational Learning: Identify themes and trends from patient concerns and partner with clinical and operational leaders to ensure patient feedback informs quality, safety, and patient experience improvement initiatives.
- Early Warning System: Recognize and escalate patient concerns that may signal emerging safety, quality, or system issues, supporting a proactive approach to harm prevention and service improvement.
- Patient Voice Integration: Collaborate with the Director of Patient Experience to ensure patient feedback and lived experiences are incorporated into governance discussions, improvement initiatives, and the Grievance Committee.
Essential Skills
- Problem Solving & Resolution: Demonstrate strong analytical and problem-solving skills to effectively investigate and resolve complex patient concerns.
- Communication: Possess excellent communication skills (written and verbal) to effectively interact with patients, families, staff, and leadership, often in sensitive situations.
- Empathy & Compassion: Exhibit a high degree of empathy, compassion, and cultural sensitivity when interacting with a diverse patient population.
- Collaboration & Teamwork: Work collaboratively with the Patient Relations team, the Director of Patient Experience, and other departments to achieve shared goals.
- Regulatory Compliance: Maintain current knowledge of CMS and DMH guidelines for complaint management.
- Data Utilization: Contribute to the interpretation and analysis of patient experience data to identify opportunities for improvement.
- Continuous Improvement: Actively participate in efforts to identify actions for CHA to achieve national best practice status with respect to patient experience.
- Discretion & Confidentiality: Maintain the highest level of discretion and confidentiality regarding patient information and sensitive issues.
- Systems Thinking: Ability to recognize patterns in patient concerns and connect individual experiences to broader opportunities for quality, safety, and system improvement.
Qualifications
Education:
- Bachelor’s degree required; degree in psychology, counseling, nursing, social work, public health, or a related clinical or behavioral health field preferred. Experience may be substituted in lieu of degree.
- Master’s degree preferred.
Experience:
- Minimum of three years' experience in patient relations, patient advocacy, or a similar role within a healthcare setting.
- Experience working with diverse patient populations is strongly preferred.
- Bi-lingual skills are preferred.
Skills:
- Demonstrated ability to manage and resolve complex complaints and sensitive issues.
- Strong understanding of patient rights and advocacy principles.
- Ability to work independently and as part of a team in a fast-paced environment.
- Proficiency in relevant software applications for documentation and reporting.
- Ability to understand and apply regulatory guidelines (CMS).
- Strong organizational skills and attention to detail.
Please note that the final offer may vary within the listed Pay Range, based on a candidate's experience, skills, qualifications, and internal equity considerations.
Location: 1035 Cambridge Street, Cambridge, MA
Work Days: 8:00am - 4:30pm
Department: Patient Experience and Complaints
Job Type: Full-time
Work Shift: Day
Hours/Week: 40
Union Name: Non-Union
Not Specified
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