Public Consulting Group Healthcare Compliance Investigator II in Dover, Delaware
Overview Healthcare Compliance Investigator II in North Carolina 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 services. SSO is committed to a diverse workforce, which is a reflection of our clients and the people they serve. Responsibilities Healthcare Compliance Investigator II 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 records. When 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.e. record request letters, tentative notice of decision letters, appeal summaries, etc. using standard templates. Communicate 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. Qualifications 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. EEO Statement Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work. Connect With Public Consulting Group! Connect with Public Consulting Group > Job LocationsUS | US-NC-Chapel Hill Posted Date4 weeks ago(11/10/2021 8:58 AM) Job ID 2021-7356 # of Openings 1 Category Clinical Review Type Regular Full-Time Practice Area Health Services
Public Consulting Group is an equal opportunity employer. All qualified applicants receive consideration for employment without regard to race, color, religion, gender, national origin, age, sexual orientation, gender identity, protected veteran status, or status as a qualified individual with a disability. VEVRAA Federal Contractor.
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