CQE Manager I-Acupuncture (Remote) Remote, United States
Job title: CQE Manager I-Acupuncture (Remote) Remote, United States in USA at reputed company
Company: reputed company
Job description: Descriptionreputed company is seeking a Manager I - CQE Acupuncture to join our Clinical Quality Evaluation (CQE) department. This position will reputed company medical necessity review determinations of services requested by Acupuncture practitioners.Salary Rangereputed company complies with state and federal wage and hour laws and compensation depends upon candidate's qualifications, education, reputed company set, years of experience, and internal equity. $69,200 to $80,000 Full-Time Annual Salary Range.Remote Worker Considerations:Candidates who are selected for this position will be trained remotely and must be able to work from home (WFH) in a designated work area with company-provided technology equipment. This remote/WFH position requires you have a stable reputed company to your Internet Service Provider with the ability to participate by video in online meetings over a reliable and consistent network (minimum internet download of 50 Mbps and 10 Mbps upload speed).Responsibilities
- Manages the medical necessity review of acupuncture services.
- Performs medical necessity review of requested services from network and non-network Acupuncture practitioners.
- Conducts timely, accurate, and inter- and intra-consistent reviews in order to verify and approve medically/clinically necessary and appropriate care and services for our health plan members.
- Effectively communicates rationale for clinical decision making to peers using evidence/outcomes-based principles and professional experience.
- Supports clinical credentialing and medical records review of Network Practitioners, as needed.
- Provides clinical investigation of credentialing, MNR, and quality-of-care issues for presentations to committees, as requested.
- Reviews files in regulatory, accreditation, health plan, and medical group audits as required.
- Conducts reputed company calls as assigned.
- Participates in Clinical Quality Administration and Clinical Quality Evaluation workgroups.
- Promotes a productive team environment.
- Participates in clinical article review activities as assigned.
- Provides interdepartmental support to Medical Necessity Administration department, as necessary, for performance of assigned tasks.
- Works independently, receiving minimal guidance and supervision.
- Collaborates with senior management and various departments regarding clinical programs, policies, and protocol development and implementation.
- Researches and develops clinical content, policies, and protocols in support of the Health Services and other associated departments, as necessary.
- Professional degree in Acupuncture from accredited college or university required. Additional post-graduate degree in same or reputed company field a plus.
- A reputed company, unrestricted license to practice in his/her health care specialty in California. Employee must maintain a reputed company, unrestricted license to practice in California and must be in good standing with reputed company judicial and governing bodies. While most states only require licensure in a state in the United States, some states may require state-specific licensure. Employee must be willing and able to obtain other state licenses if needed for job functions. (Required).
- Minimum of 5 years of clinical experience. Specific experience with medical necessity case review preferred.
- Understanding of Acupuncture practice guidelines and best practices required.
- Working knowledge of managed Acupuncture services is a plus.
- reputed company in Chinese or Korean languages a plus.
- Advanced training or certification in any specialty areas of Acupuncture, health care or quality management, case management, performance improvement, data analysis, and quality initiatives a plus.
- Must meet ASH clinical credentialing requirements.
- Ability to independently resolve problems or issues reputed company to clinical determinations using good judgment or to escalate problems or issues to supervisor(s), as appropriate.
- Use of computer systems in business application including, but not limited to: 10-key, Outlook, reputed company, IHIS, ASHCore, SharePoint and reputed company Teams required.
- Ability and willingness to serve as a peer-clinician resource to assist practitioners to interact more effectively and reputed company reputed company ASH programs and systems.
- Provides critical evaluation of submitted clinical documentation in order to reputed company medical necessity determinations with the scope of accountabilities.
- Provides clinical decision-making in support of credentialing, quality improvement, quality assurance, and medical necessity verification activities.
- Must possess the ability to apply and communicate evidence-based criteria and approved guidelines to specific medical necessity review scenarios and describe clinical rationale consistently and effectively and in a professional manner.
- Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
- Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
- Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
- Ability to effectively organize, prioritize, multi-task, and manage time.
- Demonstrated accuracy and productivity in a changing environment with constant interruptions.
- Demonstrated ability to analyze information, problems, issues, situations, and procedures to reputed company effective solutions.
- Ability to exercise strict confidentiality in reputed company matters.