Company Statement
ConnectiCare is a leading health plan in the state of Connecticut. ConnectiCare’s mission is to make it easy for members to get the care they need. A local company for over 35 years, ConnectiCare has a full range of products and services for businesses, municipalities, individuals and those who are Medicare-eligible. A subsidiary of EmblemHealth, ConnectiCare leads the individual and small group markets in the state, and is ranked among the top commercial health plans in the nation, according to the National Committee for Quality Assurance.
We’re looking for individuals who want to make a difference in the communities we serve. If you want to join a local team and help change the way health care is delivered, ConnectiCare is the place for you.
Quality & Training Analyst (Clinical) - Medical Management Operations
Summary of Job: Partnering with the Medical Management Operations Senior Leadership in maintaining an effective quality and training program to ensure clinical and operational regulatory adherence with Federal, State and CMS regulations and NCQA accreditation requirements through monitoring and educational activities.
Responsibilities:
• Perform routine clinical quality monitoring/audits, to measure adherence with state, federal, accreditation and business requirements associated with concurrent review utilization management requirements.
• Assists the Manager in planning and executing against the established concurrent review monitoring work plan.
• Performs clinical components of mock audits, such as CMS, NCQA and State, on a routine basis with attention to the clinical documentation.
• Provide quality results, documenting issues and ensures appropriate corrective actions plans are deployed, including effectiveness therein. Provide coaching to staff on individual results, sharing feedback and expected improvements to direct leaders.
• Assist the Manager with coordination of the Medical Management Operations team for state, federal, accreditation and internal audits.
• Validation of universes associated with Federal, State and Accreditation utilization audits
• Preparation of Case Files
• Participant in all external regulatory and accreditation audits
• Development of effective corrective action plans with departmental leadership
• Assist departmental management in the development of concurrent review processes and procedures and lead efforts to create effective training modules to ensure regulatory and accreditation adherence.
• Assist with the clinical new hire orientation and training, annual training and ad hoc training for end to end concurrent review processes.
• Track completions of other trainings and required evaluations annually, including mandatory trainings and clinical evaluations such as interrater reliability studies.
• Maintains a working knowledge of relevant issues, laws, and regulations affecting Medical Management Operations.
• Assists the Manager in annual review of the regulatory adherence grid, incorporating applicable Federal, State and accreditation decision-making and notification timeliness requirements.
• Performs other tasks as assigned.
Qualifications:
• Must have current, unencumbered NYS or Connecticut RN license
• 3 years’ experience in a managed healthcare environment required
• 2+ years of previous quality/audit and training experience required
• Prior experience with CMS regulations and NCQA accreditation required
• Strong communication and presentation skills and the ability to interact with all levels of management and state, federal regulatory and accreditation
• Excellent analytical, organizational, and problem solving skills
• Ability to multi-task many projects simultaneously
ESSENTIAL JOB FUNCTIONS:
• Primarily sedentary
• Must be able to use standard office equipment
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.