[Hiring] Compliance Manager @Rising Medical Solutions

Role Description

The Compliance Manager is responsible for managing all state-managed care plans. 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.

• 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.

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.

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.

Qualifications

• 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

Reports to

• CCO and VP of Medical Review Services