Sharp HealthCare

Auditor

• Responsible for the administration of Sharp HealthCare's (SHC's) compliance audit program.
• Provides oversight and maintenance of a high-quality, effective, best practices coding, billing, and reimbursement audit compliance program to prevent and detect violations of law and other misconduct.
• Help promote ethical practices and a commitment to compliance with applicable federal, California, and local laws, rules, regulations, and internal policies and procedures.
• Plays a key role in oversight of Sharp HealthCare's compliance audit function and maintaining Sharp HealthCare's view of coding, billing and reimbursement compliance audits.
• Performing all audits and chart reviews required for inpatient and/or outpatient coding and billing.
• Conducts daily retrospective chart reviews and communication to key stakeholders regarding audit findings and corrective actions, if necessary.
• Reviews the electronic health record to identify potential coding and billing compliance issues.
• Prepares written reports of audits, including recommendations to improve compliance.
• Analyzes and assesses Sharp’s potential risks using SHC’s billing and coding claims data, risk assessment data, MDAudit risk analyzer software, OIG Work plan, CMS, PEPPER Reports, RAC Denials, industry experts, etc.

Compliance Coding Auditor

Customer Support

• Responsible for direct and timely communication between the Plan and Plan members, potential members, providers, employer groups, brokers, internal departments and external agencies.
• Maintains high level of knowledge regarding Plan products, premiums, benefits and procedures.
• Uses knowledge and judgment to select appropriate resources for assisting callers.
• Provides information on all aspects of Plan products, premiums, benefits, policies and procedures.
• Responsible for accurate problem-solving.
• Researches and resolves concerns.

Customer Care Representative – SHP Operations

Manager

• Perform acute and ambulatory case management, utilization management and claims review activities
• Authorization of medically necessary patient care services and referrals using Sharp Health Plan Medical Policies and Milliman Care Guidelines
• Ensure denial letters include individualized denial reasons and alternate plan of care
• Coordinate care between physicians, specialists, vendors, community services, and caregivers
• Develop care plans with patient and family physician for acute or community based services
• Maintain detailed, accurate and timely data files on each client
• Provide prospective, concurrent, retrospective and claims review and care management services
• Conduct telephonic or onsite assessments, care planning, arranging and coordinating services, and monitoring
• Ensure provider compliance with plan standards and guidelines
• Educate clients, providers, medical groups and hospitals regarding plan benefits and resources
• Serve as trainer/mentor for new case managers during first 90 days
• Participate in testing UM and CM applications and special projects
• Develop and maintain monthly utilization and case management reports and analysis of statistics

RN Case Manager, Health Services

• Accountable for development and implementation of Hospital Case Management (HCM) and Ambulatory Case Management (ACM) programs
• Manage operations of HCM and ACM departments including Pharmacy, referral management, prior authorization, case and disease care management
• Develop, implement, and update HCM/ACM/Pharmacy policies and procedures in accordance with NCQA, legislative, and health plan requirements
• Provide direct supervision, leadership, mentoring and staff development for HCM and ACM staff
• Coordinate interdepartmental projects and represent SCMG in internal and external quality initiatives
• Ensure regulatory and legislative compliance and timely submission of utilization, case management and disease management work plans
• Develop and manage departmental budgets and identify cost savings strategies
• Implement reporting systems, analyze operational and quality outcome indicators, and report results to Quality of Care Committee

Compliance Coding Auditor

Customer Care Representative – SHP Operations

RN Case Manager, Health Services

Manager, Integrated Case Management