Medical Claims Review Manager jobs in South Carolina

External Quality Review (EQR) Specialist

Remote

Who We Are:

Constellation Quality Health, formerly CCME, is a non-profit health care quality organization and QIO-like Entity certified by the Centers for Medicare & Medicaid Services (CMS) founded by physicians in 1983. Headquartered in North Carolina’s Research Triangle, we offer an array of quality improvement, clinical review, audit, technical, and consulting services and solutions to improve care delivery, system performance, and patient outcomes.

What You’ll Do

We are seeking a Quality Review Specialist to conduct external quality review activities of health plans to determine compliance with state and federal requirements. The specialist is responsible for timely interpretation and analysis of information provided to support contract compliance and quality improvement while maintaining positive professional working relationships with contract staff, program leaders, and health plans.

We expect you to:

• Serve as Mental Health Parity Lead Reviewer ensuring ongoing operational compliance with the federal Mental Health Parity and Addiction Equity Act (MHPAEA) and state mental health and substance use disorder treatment Parity laws (“Parity”).
• Assist in the creation and maintenance of the Mental Health Parity Compliance Review process including: developing and updating review tools, providing training, developing metrics, and reporting.
• Assist with development of methodologies and data collection tools.
• Conduct desk and onsite document and program reviews.
• Interview health plan staff during onsite visits and provide technical assistance as needed.
• Develop narrative reports inclusive of findings and recommendations.
• Provide technical expertise.
• Provide maximum value to the customer.
• Serve as a positive and supportive team member.
• Stay abreast of EQR requirements, state, and federal regulations.
• Travel occasionally.

Position works remotely; however, some travel may be required. Candidates in South Carolina and North Carolina are preferred.

Who You Are:

The successful candidate meets the following requirements:

• Bachelor’s Degree from an accredited college or university in related field with at least 3-5 years of related experience.
• Experience with managed care, federal and/or state regulations, quality improvement and compliance oversight.
• Strong background in Utilization Management (physical and behavioral health) standards, processes, and reporting.
• Experience in quality management and improvement methodologies.
• Knowledge of claims, quality management, credentialing, appeals & grievances.
• Certified Professional Healthcare Quality (CPHQ), Certified Fraud Examiner or Clinical Licensure preferred.
• Knowledge of Medicaid managed care delivery systems and current healthcare trends
• Experience with Medicaid populations, programs, and policies.
• Experience with Medicaid managed care or healthcare compliance.
• Excellent communication skills to include report writing, development and delivery of content for health plan or provider education.
• Knowledge of URAC or NCQA accreditation standards and/or HEDIS certification a plus

Why Constellation Quality Health

We offer a competitive salary and benefits package and a flexible, supportive work environment.

Equal opportunity employer of protected veterans

Equal opportunity employer of individuals with disabilities

We do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, gender identity, national origin, medical condition, disability, veteran status, or any other basis protected by law.

Applicants and employees are protected from discrimination based on inquiring about, disclosing, or discussing compensation or the compensation of other applicants or employees.