Gerente De Operaciones Clinicas

Gerente de Operaciones Clinicas




GENERAL DESCRIPTION:

Monitors, audits, and ensures that pre-service requests and reconsiderations (appeals) received at the Company are processed following applicable regulations according to the line of business.

ESSENTIAL FUNCTIONS:

* Oversees, monitors, audits, and ensures that services related to the Organizational Determination process follow Centers for Medicare and Medicaid Services (CMS) and/or applicable regulations of both lines of business.
* Monitors compliance with established time limits, both regulatory and operational, for both lines of business, achieving unit compliance in overall reporting.
* Oversees and monitors aging reports to identify potential non-compliance cases. Takes appropriate action with supervisees and ensures equitable distribution of cases amongst team members.
* Oversees unit workflows and supervisor's work plans to comply with established regulations, policies, and procedures.
* Supervise the internal audits for the quality of data entry through various regular reports.
* Performs random sample audits regularly for early identification of findings.
* Maintains and monitors metrics to ensure that organization determination requests are set up promptly and following the established schedules.
* Performs the monthly program of the supervisors in charge.
* Develops corrective action plans according to the root cause of non-compliant situations. Supervise the documentation organization of the team for easy root cause analysis and determine the need for reinforcement and/or retraining in conjunction with supervisors.
* Oversees the new employee training programs in conjunction with clinical trainers and supervisors. Performs retraining interventions with a clinical focus, process reinforcement, and/or re-engineering as needed.
* Identifies providers with barriers and/or deficiencies in submitting the necessary information for the applicable process.
* Maintains revised and updated materials, policy and procedure distribution, and unit operational manuals according to changes and/or operational needs.
* Provides clinical support to Grievance and Appeals staff on Administrative Organizational Determinations (AOD) requests.
* Establishes service alliances with critical areas at the interdepartmental level to develop strategies with the supervisory team of the various Clinical Affairs units to achieve efficiencies in the flow of requests. Works and provides support with special projects as assigned.
* Supervises, monitors, trains, evaluates, and corrects personnel among others to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions and that they behave following the policies, standards, norms, and procedures of the Company.
* Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
* May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience: Bachelor's Degree in Nursing Sciences from an accredited institution. At least five (5) years of experience in clinical areas. At least two (2) years of experience supervising staff.

Certifications / Licenses: A valid Nurse & Association Nursing Professionals of Puerto Rico license and registration.

Other: Knowledge of clinical criteria, ICD-10, and CPT.

Languages:
Spanish – Advanced (comprehensive, writing and verbal)
English – Advanced (comprehensive, writing and verbal)




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