PURPOSE OF POSITION:

The primary purpose of the Quality & Medical Management Supervisor is responsible to coordinate and supervise the day to day functions of the medical management department in an efficient, cost-effective manner in accordance with governing and accrediting bodies' policies and standards. The Quality & Medical Management Supervisor offers guidance to the staff to assure all applicable laws, rules, guidelines, policies, URAC standards and contractual requirements are adhered to. The Quality & Medical Management Supervisor will accomplish this goal by devoting on average thirty to forty percent of their time on quality outcomes. Continually leading by example to provide and facilitate efficient, quality service at all times.

RESPONSIBILITIES & EXPECTATIONS:

• Establish, maintain and enforce policies and procedures to conform to all governing and accrediting bodies to include but not limited to: URAC, Ohio Bureau of Workers' Compensation (BWC), and the Industrial Commission(IC). Coordinate the URAC Accreditation process:
  • Primary contact
  • Manage all incoming and outgoing communications.
  • Assure attestation and any organizational changes are completed timely.
  • Build the URAC application and its submission to the URAC Accreditnet portal.
  • Coordinate the on-site audit and assure all documentation is available and flagged for their review.
  • Collect, analyze and report performance measures as required by URAC.
• Coordinates quality improvement data collection/evaluation process:
• Collects/evaluates data for medical management, vocational rehabilitation, billing, first report of injury and other processes, as needed.
• Reports findings to the management staff at AultComp MCO and the Quality Taskforce.
• Develops quality work and action plans.
• Writes and maintains QI projects as determined by the QI Taskforce.
• Coordinates and/or oversees audits:
  • BWC Audits and/or responses to CAR
  • Internal Audits
  • Assists Manager and Systems & Finance Analyst with SSAE16 Audit
• Coordination of policymaking regarding AultComp MCO's/BWC's guidelines and policies. Evaluates and coordinates AultComp MCO policy changes to remain compliant with URAC standards.
• Provides educational support for staff, injured worker, medical provider, and employer regarding the workers' compensation process, URAC, BWC/AultComp MCO guidelines.
• Documents clear concise notes in the system following activity on cases.
• Process Improvement: Continuously reviews, recommends and implements improvement steps, as needed or directed.
• Seeks supervisory guidance/approval as appropriate.
• Portrays professional image: follows dress code; communicates with internal and external customers in a professional manner, including appropriate verbal and written grammar.
• Promotes and demonstrates professional standards to enhance the development of the department including:
  • Performs all job functions in an independent manner (as needed or directed)
  • Recognizes and performs job functions with little or no supervision
  • Demonstrates strong organizational skills
  • Responds positively to change in work flow as needed
  • Offers assistance to co-workers (as needed)
  • Maintains flexibility to meet department needs, including adjusting work hours
  • Consistently completes assigned work in required time frame; completes other duties as required
  • Collaborates and cooperates with co-workers, supervisors, etc., creating a productive working relationship throughout the organization
  • Actively seeks and pursues opportunities to make a contribution and demonstrates desire for learning
• Practices Ethical Conduct:
  • Demonstrates honesty and integrity in all functions and relationships
  • Maintains AultCare standards of confidentiality, including HIPAA privacy guidelines
  • Complies with policies and procedures at all times
• Meets acceptable attendance and punctuality expectations (excluding FMLA)

The above statements reflect the general duties considered necessary to describe the principle functions of the job as identified, and shall not be considered as a detailed description of all the work requirements that may be inherent to this position.

AultCare/AHF will provide reasonable accommodations to employees or applicants with disabilities, as defined by the Americans with Disabilities Act, who are otherwise qualified to safely perform the essential functions of the job, with or without accommodation, unless such accommodation would constitute an undue hardship on AultCare/AHF or poses a direct threat to the health and safety of the individual or others that cannot be sufficiently mitigated by reasonable accommodation. Any applicant or employee who requires an accommodation to perform the essential functions of his or her job or to enjoy equal benefits and privileges of employment should notify the AultCare Human Resource Department and request such accommodation.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender identity, sexual orientation, or protected veteran status. AultCare is an EEO/AA Employer M/F/Disability/Vet.

QUALIFICATIONS:

Education:

• Licensure or certification in a health related field that allows the professional to conduct an independent assessment as permitted with the scope and practice of the discipline.
• Two or more years of experience in direct clinical care. Preferably in orthopedics and/or occupational clinic setting.
  • Ohio Bureau of Workers Compensation medical case management a plus.
• One or more of the following:
  • Certification as a case manager as described in the policy "Recognition of Case Management Certification
  • A bachelors (or higher) degree in a health related field
  • Current, valid, unrestricted registered nurse license (RN) in the State of Ohio
• At least three years' experience as a case manager
• After three or more years of directly managing and supervising case managers, the AultComp MCO Medical Management Supervisor shall have obtained and hold a certification as a case manager.
• Maintains professional licensure/certification.
• Remains current in educational areas related to job description.
• Organized self-starter with focus on goals and deadlines.
• Previous experience utilizing spreadsheet, database or related software preferred.
• Requires excellent interpersonal skills and evaluation skills.

WORKING CONDITIONS:

• Hours of operation, shifts as assigned. Occasional overtime, on-call, off-shifts (evenings and/or weekends) scheduled as necessary.
• Lunch and break periods must be coordinated with other staff members to maintain adequate office staffing during departmental operating hours.
• Sitting/standing/moving about intermittently during working hours.
• Subject to frequent interruptions and changes in priority of duties throughout the day.