Clinical Compliance Program Manager

About the Role

WellSky is seeking a dedicated Clinical Compliance Program Manager to ensure adherence to our Utilization Management and Compliance Program. This role requires a clinical expert to interpret state and federal regulations and analyze data to establish best practices across various post-acute healthcare settings, including LTACHs, IRFs, SNFs, and Home Health facilities. Join us in shaping the future of healthcare!

Key Responsibilities

• Facilitate performance measurement and outcomes activities, ensuring the organization meets CMS, NCQA, and other regulatory standards.
• Stay updated on relevant regulatory changes and support their integration into practices.
• Comply with state, federal, and organizational standards by assisting in the development and enforcement of policies aligned with Utilization Management and Compliance requirements.
• Complete and successfully submit CMS reports: ODAG, Part C, Reopening, and Complaints and Grievance Reports.
• Conduct Root Cause Analysis (RCA) with Operational teams.
• Conduct regular compliance audits based on CMS UM standards for expedited, standard, and other case statuses.
• Develop and guide the implementation of internal audit protocols in compliance with CMS regulations and NCQA standards.
• Contribute to the consistency of clinical documentation and decision-making processes.
• Generate and validate reports to monitor performance and compliance across health plan contracts, ensuring accuracy and alignment with requirements.
• Prepare for regulatory, accreditation, and contractual audits, and contribute to the remediation and documentation of audit findings.
• Perform other job duties as assigned.

Required Qualifications

• At least 4-6 years of relevant work experience.
• Advanced working knowledge of CMS UM audits.
• At minimum, 2-3 years of compliance experience focused on CMS and health plan audits.
• At minimum, 1-2 years of implementing CMS final rule changes and managing change management of processes.
• Bachelor's Degree or equivalent work experience.

Preferred Qualifications

• Active, unrestricted license: RN, PT, OT, or SLP, with a bachelor’s degree in a related field or a combination of education and experience that includes pertinent clinical experience and advanced working knowledge of CMS standards and guidelines.
• Experience with NCQA audits.
• Must be able to prioritize, plan, and handle multiple tasks and demands simultaneously, with competing deadlines.
• Excellent skills in manipulating and sorting data for analytics and reporting.
• Prior experience owning client compliance SLAs and ensuring success in meeting SLA requirements.

Job Expectations

• Willingness to work additional or irregular hours as needed.
• Must work in accordance with applicable security policies and procedures to safeguard company and client information.
• Must be able to sit and view a computer screen for extended periods of time.

About WellSky and Benefits

WellSky is where independent thinking and collaboration come together to create an authentic culture. We thrive on innovation, inclusiveness, and cohesive perspectives. At WellSky, you can make a difference.

WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, physical or mental disability, protected medical condition, genetic information, military service, veteran status, or any other status or characteristic protected by law. WellSky is proud to be a drug-free workplace.

Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates.

Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky:

• Excellent medical with Rx, dental, and vision benefits
• Mental Health support through EAP
• Generous paid time off, plus 13 paid holidays
• 100% vested 401(K) retirement plans
• Educational assistance up to $2500 per year

Key skills/competency

• Clinical Compliance
• Program Management
• Utilization Management
• CMS Regulations
• NCQA Standards
• Auditing
• Root Cause Analysis
• Healthcare Analytics
• Regulatory Compliance
• Policy Development