Public Consulting Group Provider Management Supervisor - 2018-3101 in Peoria | US, Illinois

This job was posted by https://illinoisjoblink.illinois.gov : For more information, please see: https://illinoisjoblink.illinois.gov/ada/r/jobs/5620052 Overview

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The Nurse Supervisor of Illinois Home and Community Based Waiver must be highly motivated, strong in verbal and written communication, and dependable with an interest in public service to be part of the IL HCBS Waiver Review team. This position is primarily responsible for the supervision of Nurse Reviewers.

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Responsibilities

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Monitor processes for analyzing quality and investigating fraud, waste, and abuse complaints from various sources including, but not limited to beneficiary complaints, online email complaints, providers, and outside agencies and departments.

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Support investigations process through research; using claims data resources, medical records, case management documentation, and/or conduct interviews with related parties.

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Evaluate investigator case evidence to assure it clearly support a conclusion of substantiated or unsubstantiated fraud, waste, and abuse for management approval.

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Complete quality assurance reviews for investigative reports.

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Assist in the development of identifying aberrant billing patterns or trends on internal and external data that may highlight potential behaviors in the provider's billing.

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Assist investigators as needed to respond to complaints, preliminary, and full investigation in a timely manner as outlined in the product protocol and processes

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Monitoring case tracking and assignment of investigations.

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Assist with investigation as needed, including but not limited to: Coordination with external entities for referrals as needed

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Assure compliance with protocols for investigations and routine review

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Resource for review of relevant documentation, which may include but not limited to, credentials of staff, aide logs, supervisor visit notes, Independent Assessment, service authorization, clinical notes, communication notes, nurse's notes, and provider billing

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Documentation of investigative activities including but not limited to, discovery of all elements of the incident/complaint, answering who, what, when, where, and how (if applicable); interviews with witnesses, complainant, provider and/or staff, recipient

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Assist with or complete other duties as assigned

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Qualifications

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Ability to review, organize, and analyze voluminous and complex medical records and other pertinent healthcare and legal documents

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Demonstrate experience with developing collaborative case strategies and making recommendations by preparing factual analysis of healthcare fraud schemes

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Demonstrate experience planning and conducting complex provider Quality investigations

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Ability to define problems, analyze alternatives and recommend solutions to difficult healthcare investigative problems or issues.

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Ability to work irregular hours (including nights and weekends) as needed

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Ability to travel for extensive periods of time as needed (80-90%)

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A valid driver's license

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n Required Skills: n

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Proper etiquette including customer relation techniques, superior verbal and communications skills

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Ability to think critically, incorporation of multiple factors into larger concept

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Strong decision making, accuracy and attention to detail

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Experience in meeting deadlines and adhering to strict standards

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Ability to work with and relate to staff and demonstrate active listening skills

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Display professionalism and respect for cultural differences

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Skilled in the use of MS Word, Excel, Outlook, the internet, and other common IT systems.

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Ability to foster teamwork with all levels of management and staff

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Ability to work well independently and within a team

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n Education and Experience: /strong>n

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+ Bachelor's Degree in a health-related field, preferably in Nursing


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+ Active and unrestricted Illinois Registered Nurse license


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+ 2+ years paid experience working with critical care providers, public health providers, or providers that care for children, older adults, persons with traumatic brain injury, or persons with developmental disabilities

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+ One year of the experience must have been in a home health program, community health program, hospital, private practice, publicly-funded institution, long-term care program, mental health program, community-based social service program, or any other program addressing the needs of special populations


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+ At least 1 year of quality assurance/auditing experience preferred

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+ minimum of two (2) years of experience in managing quality assurance activities.

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+ The RN supervisor will be responsible for staff supervision and management of contractual requirements, milestones and deliverables.

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+ Public sector experience a plus

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+ Strong analytical, organizational, and time management skills any equivalent combination of the required experience

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+ Previous healthcare audit and quality review experience preferred.


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#LI-HM1

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