Job details
Job type full-time
Full job description
Staffing solutions organization llc (sso), a wholly owned subsidiary of public consulting group, is focused on delighting clients with world-class managed staffing and talent consulting servicesSso is committed to a diverse workforce, which is a reflection of our clients and the people they serve.
Position title: healthcare compliance investigator 2 - temporary to permanent location: north carolina
Duties & responsibilities:
Investigate complaints, initiatives and data packages against north carolina (nc) medicaid providers and conduct desk and routine reviews of assigned providers to determine compliance with clinical policies, licensing rules, state and federal regulations.
Conduct thorough investigations of all complaints and routine reviews including an analysis of all relevant medical, training, credentialing and billing recordsWhen necessary, conduct interviews with individuals who may have relevant information, document all investigative activities, including discovery of all elements of the incident in the case tracking management system.
Prepare case mailings, i.eRecord request letters, tentative notice of decision letters, appeal summaries, etcUsing standard templatesCommunicate with nc medicaid providers to obtain documentation, provide education as needed, and to address and attend reconsideration appeals as necessary.
Create a thorough written report to document the results of the investigations and to recommend corrective actions to the nc division of health benefit (dhb) office of compliance and program integrity.
Create written referrals when appropriate to the division of health service regulation, the health care personnel registry, the nc board of nursing, or other entity as determined through document review
Gather information to write and submit referrals to nc dhb office of compliance and program integrity for egregious provider behavior
Review and approve provider corrective action plans.
Provide weekly status updates to supervisor of all open cases and cases under appeal.
Act as mentor to new or less experienced investigators.
Other duties as required by project.
Required skills:
Demonstrate ability to think critically, incorporating multiple factors into larger concepts
Strong organizational skills with abilities to simultaneously manage multiple (8 to 12) investigations of 3-5 service provider types
Demonstrate ability to work with and relate to others with customer relation techniques, professionalism and with respect for other cultures
Demonstrate effective active listening and interviewing skills
Strong computer skills with competence in ms word, excel, outlook and teams
Demonstrate ability to foster teamwork with all levels of management and staff
Demonstrate ability to work well independently and within a team
Superior verbal and written communication skills
Strong and independent decision-making skills, with accuracy and attention to detail.
Qualifications:
Education: registered nurse (rn)-unrestricted license in north carolina or compact state
Experience:
5+ years paid experience in nursing.
At least 2 years’ experience in nc home and community-based service (hcbs), specifically experience with any of the following: home health care, medicaid waiver programs, incident investigation, quality assurance, and/or clinical risk management.
Working conditions:
Remote-occasional travel within nc
All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, marital status, age, national origin, protected veteran status, or disability.
Staffing solutions organization llc is an e-verify participant.
