Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.
Qlarant has an immediate need for a Medicaid SME RN to provide an advanced level of Medicaid expertise on procedure/diagnosis and risk of policy vulnerability, especially as it relates to DMEPOS, Behavioral Health or Opioids/SUD. This position conducts Medicaid policy research and reviews of related data analysis provided by Qlarant's data analytics team. The selected candidate can be home based in most areas of the country. We offer an excellent benefits package that includes medical, dental, vision, short and long-term disability, generous vacation, sick and holiday leave and two retirement plans.
Essential duties include but are not limited to:
- Receive vulnerability assignment from client for topical area or specific service category
- Research past actions/evidence regarding the assigned topical area – this is normally through OIG reports, legislative audits, change in policy, etc. Capture and comment on evidence in provided documents on SharePoint.
- Research State specific policies/federal regulations to assist in supporting position on vulnerability
- Write up identified vulnerabilities to present to the client to determine if accepted as a pursuable vulnerability for the area – there are times when they determine certain vulnerabilities belong under a broader topic e.g. provider enrollment
- Assist as needed in the development of the risk assessment document setting forth vulnerabilities accepted and developed. This includes background, evidence information, scoring of the vulnerability in conjunction with other members of the team.
- Provide support throughout the project as a SME as needed
- Attend as requested Vulnerability Collaboration Council (VCC) meetings to discuss presented and accepted vulnerabilities
- Provide recommended language in response to questions from client on any documents submitted where SME is needed/requested
- Research ad hoc topics for FAST forms which in essence is a quick turnaround for a smaller topical area where the client is in need of some immediate information
- Provide support as needed for vulnerability summaries and next steps throughout the process
- Attend regularly scheduled project meetings as necessary with client, and breakout groups depending upon the topic (internal team) and task
Required Skills
To perform the job successfully, an individual should demonstrate the following competencies:
- Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.
- Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations.
- Project Management - Develops project plans; Coordinates projects; Communicates changes and progress; Completes projects on time and budget; Manages project team activities.
- Customer Service - Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
- Delegation - Delegates work assignments; Matches the responsibility to the person; Gives authority to work independently; Sets expectations and monitors delegated activities.
- Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
- Business Acumen - Understands business implications of decisions; Displays orientation to profitability; Demonstrates knowledge of market and competition; Aligns work with strategic goals.
- Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; Supports organization's goals and values; Benefits organization through outside activities.
- Judgment - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
- Planning/Organizing - Prioritizes and plans work activities; Plans for additional resources; Sets goals and objectives; Develops realistic action plans.
- Other Skills and Abilities
- Must demonstrate the ability to design, implement, and monitor systems.
- Ability to interpret financial reports, monitor budgetary allocations and allocate resources to meet change contract needs.
Required Experience
- BSN or RN and Bachelor's degree in a relevant field required
- At least five years clinical experience required.
- Must possess subject matter expert level knowledge of Medicaid policy as well as procedure/diagnosis.
- Medicaid experience involving DMEPOS, Behavioral Health or Opioids/SUD preferred.
- ICD-9 coding and CPT coding experience preferred.
- Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies required.
- Senior leadership skills and the ability to interact with all levels of personnel, including state and national collaborations required.
Certificates, Licenses, Registrations: Current, active and non-restricted RN licensure required.
Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.
Qualifications:
To perform the job successfully, an individual should demonstrate the following competencies:
- Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.
- Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations.
- Project Management - Develops project plans; Coordinates projects; Communicates changes and progress; Completes projects on time and budget; Manages project team activities.
- Customer Service - Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
- Delegation - Delegates work assignments; Matches the responsibility to the person; Gives authority to work independently; Sets expectations and monitors delegated activities.
- Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
- Business Acumen - Understands business implications of decisions; Displays orientation to profitability; Demonstrates knowledge of market and competition; Aligns work with strategic goals.
- Organizational Support - Follows policies and procedures; Completes administrative tasks correctly and on time; Supports organization's goals and values; Benefits organization through outside activities.
- Judgment - Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
- Planning/Organizing - Prioritizes and plans work activities; Plans for additional resources; Sets goals and objectives; Develops realistic action plans.
- Other Skills and Abilities
- Must demonstrate the ability to design, implement, and monitor systems.
- Ability to interpret financial reports, monitor budgetary allocations and allocate resources to meet change contract needs.