Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The position is responsible for planning and executing quality and oversight activities to ensure operational compliance with federal and state regulations, Capital operational standards, accreditation requirements. Responsible for ensuring internal and delegated clinical management services performed by vendors and provider partners meets Capital’s accreditation, contractual, federal and state regulations standards and will support vendor oversight according to service level agreements within contracts. Responsible for internal and external case audits for Capital and our delegated UM vendors (if applicable to assigned unit); develops and provides education as applicable.

• Responsible for planning and executing documentation/case audits (internal and external) for assigned unit (e.g. UM, CM, delegated vendor(s))
• Responsible for educating staff on findings, and the audit tool to ensure a consistent approach to documentation and case collaboration.
• Monthly, quarterly, annually and upon request, prepares written evaluation of quality and oversight activities for assigned unit(s) to ensure regulatory/accreditation/contract compliance:
  • including presentation of the evaluations and audit activities to the appropriate committees and senior management for approval.
  • Establishes appropriate benchmarks and analyzes reports to determine if utilization and quality performance are appropriate.
  • Identify opportunities for improving processes and outcomes.
  • Development and monitoring of corrective action plans and follow-up activities.
• Maintains appropriate documentation of records, reports, correspondence, training and additional quality and oversight activities to ensure comprehensive tracking of documentation that meets both regulatory and accreditation standards, including for delegation when appropriate.
• Actively engages in Capital’s compliance activities, including that of any delegated UM vendors, if applicable:
  • Monitors regulatory and accreditation standards for updates and proposes updates to Policy and Procedures as required.
  • Annually updates audit tool according to appropriate accreditation and regulatory standards.
  • Assists in ensuring that letters remain in compliance with accreditation and regulatory standards for Capital and any delegated UM vendors, if applicable for assigned unit.
• If applicable to assigned unit, development and implementation of various quality activities including:
  • IRR question development and assessment for assigned unit staff, including development and education of identified areas of opportunity,
  • Perform routine mock audits for UM, both CMS and NCQA focused.
• Participates in all regulatory and accreditation reporting activities.   
• Performs other duties as assigned.

Skills: 

• Strong communication and presentation skills. Ability to independently prepare and present outcomes reports.
• Ability to work independently, self-motivated and highly accountable.
• Demonstrated cross functional collaboration. Ability to interact with all levels both within Capital and with our delegated UM vendors.
• Demonstrated organizational and time management skills with the ability to manage multiple tasks simultaneously and deliver high quality work.
• Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions, and devise appropriate courses of action
• Knowledge of Capital’s medical policies and standard review criteria, if applicable to assigned unit.
• Knowledge of and remains current on all regulatory and accreditation requirements for assigned unit (CMS, NCQA, CHIP, etc.).

Knowledge:

• Current knowledge of accreditation and regulatory standards requirements as applicable to UM and vendor delegation, such as CMS, NCQA, JCAHO, and DOH.
• Knowledge of the health care market including an understanding of the philosophy of managed care programs and principles, including utilization management.
• Familiar with appropriate quality and oversight activities that support compliance for assigned unit.

Experience:

• Minimum of five (5) years recent clinical experience.
• Two (2) years of experience in Quality Improvement or experience with similar related activities required.
• Medical management experience, including UM preferred.

Education, Certification and Licenses:

• Must have active current and unrestricted master’s level Behavioral Health clinical license (LMSW, LCSW, LISW, LPC, or comparable) or Registered Nurse licensure.
• Certification in quality improvement preferred.

 

 

 

 

 

 

 

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.    
And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.