Key Facts

Remote From:

Full time

Mid-level (2-5 years)

English

Hard Skills

Labor Law Fraud Detection Billing Microsoft 365 Task Management Project Coordination Digital File Management Auditing Clinical Documentation Microsoft SharePoint

Other Skills

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Program Management
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Microsoft Office
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Time Management
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Teamwork
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Organizational Skills
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Verbal Communication Skills
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Diplomacy

Rising Medical Solutions

Insurance

About Rising Medical Solutions

Rising Medical Solutions is a national managed care firm that provides medical cost containment and medical care management services to the workers' compensation, auto, liability, and group health markets. Our client base includes insurance carriers, TPAs, self-insured employers, and public-sector and government entities of varying sizes from small to large tier.Since 1999, our managed care services have positively impacted hundreds of thousands of employee lives and saved billions in total claim costs for payers across the country. Our flagship bill review service and technologies consistently deliver over 60% in national bill review savings, which includes application of fee schedule/UCR rates, network discounts, nurse audits, provider negotiations, and embedded fraud detection capabilities. However, our solutions portfolio goes far beyond the standard repricing of medical bills. Our integrated programs deliver clinical and cost-saving expertise before, during, and after treatment. Our proprietary VISION™ platform is the industry’s only multi-product, multi-line, single-sign-on, medical management enterprise system. VISION™ provides claims professionals with unprecedented ancillary referral and medical management capabilities across the entire medical care continuum, from early intervention to payment processing. Together with our passionate, mission-driven employees, Rising delivers an unparalleled user experience for those providing, receiving, and paying for medical care.Rising also directs and publishes the annual Workers’ Compensation Benchmarking Study, a national research program examining the complex forces impacting claims management in workers’ compensation today. The study has become one of the most cited research publications in the industry and has been the subject of numerous articles, webinars, and conference presentations since its 2013 inception.

Company type: SME

Industry: Insurance

Founded: 2018

Company size: 51 - 200

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Job description

The Compliance Manager is responsible for managing all state-Workers' Compensation managed care plans (MPN/MCO's). He/she is focused on filing new applications and modifying existing applications as needed, manages the implementation process both internally and externally with our clients and state liaisons, and regularly reviews medical bill review state reporting laws and regulations, maintaining documentation on our Risingpedia Timely Pay site.

Core Responsibilities include:

Oversee the coordination of resources to ensure the ongoing effectiveness of the state managed care programs
Tracks applicable laws and regulations in the jurisdictions in which Rising participates in the state managed care plans
Tracks applicable medical bill review laws and regulations nationwide
Develop and maintain managed care resource materials for Rising state filings and customer worksite materials
Managed care report filings as required quarterly, semi-annually
Maintain historical archive of customer managed care filings
Proactive and diplomatic with client concerns
Active participation in cross-functional team efforts for implementation and ongoing support of client program

CA MPN Oversight

In this role, the Compliance Manager also manages the California MPN Coordinator team of Medical Access Assistants, including fostering development and understanding of MPN rules and application of those rules by way of assistance for all MPN requests from injured workers, customers, adjusters, and attorneys. The manager monitors all MPN requests received which includes the audit log and escalates appropriate solutions to delays in treatment or scheduling, tracks progression of scheduling tasks assigned to the MPN coordinator, assists with evaluation of geo analysis reports identifying areas and specialties of the MPN network in need of additional coverage and serves as backup key responder at times when the MPN coordinator is out of the office.

Regulatory Compliance

The Compliance Manager maintains the timely pay portal, regularly reviewing state regulations and rules (all states) for Medical Bill Review timely billing, payment, late paid penalties, timely reconsideration and dispute requests, explanation of review (EOR) requirements, electronic billing, and other categories as needed to ensure compliancy with these rules and updates of our timely pay dashboards. In this role, regular research of all state published updates are monitored for changes in government regulations, industry trends, and developments pertaining to Rising lines of business, and communicated to Rising staff and customers of the key changes in federal and state rules and regulations.

Provider Fraud Prevention

Management of Rising’s fraudulent provider workflow and team, including monitoring state regulatory websites for posted updates of providers who have been officially suspended or removed from participating in the workers’ compensation, or alerts of providers involved in fraudulent activity, arrests, or convictions (all states). Oversee assignments to validate reported fraudulent provider’s tax ID and NPI numbers, entry flags into our Vision system, alerting our bill auditors and utilization review nurses, should the provider be associated with a bill received or open claim.

Reports to:

CCO and VP of Medical Review Services

Requirements

Bachelor' s degree in business administration or related field and ten (10) years significant business experience, or ten (10) years of industry experience

Significant experience in research and interpretation of Workers' Compensation state managed care plans and medical bill review requirements
Proficiency with Microsoft Office applications, SharePoint, Office 365
Excellent oral and written communication skills
Excellent organizational/time management skills
Experience writing briefs and/or position papers

Benefits

Health insurance (4 different plans to choose from)
Dental
Vision
Paid time off (PTO) or Flexible Time Off (FTO)
401(k)
Basic Life Insurance and Long-Term Disability Insurance (paid by the company)
Voluntary Life Insurance and Short-Term Disability Insurance
Flexible Spending Accounts (FSA)
Employee Assistance Program (EAP)
Rise Well Wellness Program
Professional Development Reimbursement Program (PDRP)
You will be part of our new Elevate program designed to recognize and reward employees for their hard work