CQE Manager I-Acupuncture (Remote)

Description

American Specialty Health Incorporated is seeking a Manager I - CQE Acupuncture to join our Clinical Quality Evaluation (CQE) department. This position will render medical necessity review determinations of services requested by Acupuncture practitioners.

Salary Range

American Specialty Health complies with state and federal wage and hour laws and compensation depends upon candidate’s qualifications, education, skill set, years of experience, and internal equity. $69,200 to $80,000 Full-Time Annual Salary Range.

Remote Worker Considerations:

Candidates who are selected for this position will be trained remotely and must be able to work from home (WFH) in a designated work area with company-provided technology equipment. This remote/WFH position requires you have a stable connection to your Internet Service Provider with the ability to participate by video in online meetings over a reliable and consistent network (minimum internet download of 50 Mbps and 10 Mbps upload speed).  

Responsibilities

• Manages the medical necessity review of acupuncture services.
• Performs medical necessity review of requested services from network and non-network Acupuncture practitioners.
• Conducts timely, accurate, and inter- and intra-consistent reviews in order to verify and approve medically/clinically necessary and appropriate care and services for our health plan members.
• Effectively communicates rationale for clinical decision making to peers using evidence/outcomes-based principles and professional experience.
• Supports clinical credentialing and medical records review of Network Practitioners, as needed.
• Provides clinical investigation of credentialing, MNR, and quality-of-care issues for presentations to committees, as requested.
• Reviews files in regulatory, accreditation, health plan, and medical group audits as required.
• Conducts outreach calls as assigned.
• Participates in Clinical Quality Administration and Clinical Quality Evaluation workgroups.
• Promotes a productive team environment.
• Participates in clinical article review activities as assigned.
• Provides interdepartmental support to Medical Necessity Administration department, as necessary, for performance of assigned tasks.
• Works independently, receiving minimal guidance and supervision.
• Collaborates with senior management and various departments regarding clinical programs, policies, and protocol development and implementation.
• Researches and develops clinical content, policies, and protocols in support of the Health Services and other associated departments, as necessary.

Qualifications

• Professional degree in Acupuncture from accredited college or university required. Additional post-graduate degree in same or related field a plus.
• A current, unrestricted license to practice in his/her health care specialty in California. Employee must maintain a current, unrestricted license to practice in California and must be in good standing with all judicial and governing bodies. While most states only require licensure in a state in the United States, some states may require state-specific licensure. Employee must be willing and able to obtain other state licenses if needed for job functions. (Required).
• Minimum of 5 years of clinical experience. Specific experience with medical necessity case review preferred.
• Understanding of Acupuncture practice guidelines and best practices required.
• Working knowledge of managed Acupuncture services is a plus.
• Fluency in Chinese or Korean languages a plus.
• Advanced training or certification in any specialty areas of Acupuncture, health care or quality management, case management, performance improvement, data analysis, and quality initiatives a plus.
• Must meet ASH clinical credentialing requirements.
• Ability to independently resolve problems or issues related to clinical determinations using good judgment or to escalate problems or issues to supervisor(s), as appropriate.
• Use of computer systems in business application including, but not limited to: 10-key, Outlook, MS-WORD, IHIS, ASHCore, SharePoint and Microsoft Teams required.
• Ability and willingness to serve as a peer-clinician resource to assist practitioners to interact more effectively and efficiently within ASH programs and systems.
• Provides critical evaluation of submitted clinical documentation in order to make medical necessity determinations with the scope of accountabilities.
• Provides clinical decision-making in support of credentialing, quality improvement, quality assurance, and medical necessity verification activities.
• Must possess the ability to apply and communicate evidence-based criteria and approved guidelines to specific medical necessity review scenarios and describe clinical rationale consistently and effectively and in a professional manner.

Core Competencies

• Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
• Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
• Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
• Ability to effectively organize, prioritize, multi-task, and manage time.
• Demonstrated accuracy and productivity in a changing environment with constant interruptions.
• Demonstrated ability to analyze information, problems, issues, situations, and procedures to develop effective solutions.
• Ability to exercise strict confidentiality in all matters.

Mobility

Primarily sedentary, able to sit for long periods of time, able to travel by automobile and air.

Physical Requirements

Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in verbal and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs.

Environmental Conditions

Work-from-home (WFH) environment..

American Specialty Health is an Equal Opportunity/Affirmative Action Employer.

All qualified applicants will receive consideration for employment without regard to sex (including pregnancy, childbirth, related medical conditions, breastfeeding, and reproductive health decision-making), gender, gender identity, gender expression, race, color, religion (including religious dress and grooming practices), creed, national origin, citizenship, ancestry, physical or mental disability, legally-protected medical condition, marital status, age, sexual orientation, genetic information, military or veteran status, political affiliation, or any other basis protected by applicable local, federal or state law.

Please view Equal Employment Opportunity Posters provided by OFCCP here.

If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact our Human Resources Department at (800) 848-3555 x6702.

ASH will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company’s legal duty to furnish information.

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