Job Details

Immediate need for a talented Senior Clinical Services Compliance Specialist. This is a full-time opportunity with long-term potential and is located in Philadelphia, PA (Hybrid)Please review the job description below and contactme ASAP if you are interested.

Job Diva ID: 26-11544

Pay Range: $43- $46 /hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Hybrid role - candidate will need to be onsite Turs, Wed, Thurs
• Collaborate with internal and external resources to develop program improvements, and to reengineer processes to assure service and compliance quality.
• Analysis of existing databases for relevant, reliable, and accurate data.
• Development of detailed illustrated specifications for reports, and develop detailed specifications for business intelligence and ad hoc audits and reports
• Research quality issues identified through regulatory agencies, Executive Inquiries, Consent Orders, Corporate Fraud Investigations, or other referral sources.
• Develop, refine, and update data tools for various audits, including tools for ad hoc audits.
• Analyzes audit findings and identifies credentialing process problems across business areas and recommends a plan of corrective action for resolution and follow up.
• Facilitate the Credentialing Program Description and Statement of Effectiveness and Program Descriptions for review and approval.
• Participate in developing and maintaining desk procedures and processing guides.
• Conduct gap analysis between requirements and corporate policies.

Key Requirements and Technology Experience:

• Education Bachelor's Degree, clinical license or relevant work experience.
• Minimum of five (5) years in a managed care setting.
• Detailed knowledge of NCQA accreditation, CMS state and federal laws and regulations.
• Excellent organizational, interpersonal, analytical, presentation and written skills required.
• Demonstrated ability to interact effectively with all levels of staff.
• Proven ability to work independently, prioritize workflow, maintain flexibility, and work as part of the departmental team
• Serves as a team facilitator and consultative resource for the organization.
• Demonstrated effective communication and analytical skills (emphasis on written skills) with the ability to work well with and associates of all levels through the family of companies.
• Experience analyzing data and coordinating projects.
• Strong writing skills for reporting

Our client is a leading Health Insurance Industry , and we are currently interviewing to fill this and other similar fulltime positions. If you are interested in this position, please apply online for immediate consideration

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