Manager, Oncology Clinical Certifications

Company Name:
CareCore National
Job Description:
The Manager of Oncology Clinical Services oversees and coordinates the day-to-day operations of the Oncology Services Clinical Unit and works collaboratively with the Vice President of Clinical Operations to facilitate the clinical certification processes for radiation therapy services. Additional responsibilities include, but are not limited to:
Developing and managing CareCore National''s Oncology Services clinical review team in processing of telephonic or written clinical certification requests from physician offices and/or imaging centers in accordance with contractual obligations.
Developing and maintaining knowledge of CareCore Oncology Services policies and procedures and criteria related to clinical certification.
Monitoring the Oncology Services team to assure that utilization management criteria are effectively and objectively utilized for the accurate determination of medical necessity and ensure clinical certification services are compliant with CareCore, URAC, NCQA, and contractually defined standards
Maintaining data necessary to manage the Oncology Services Clinical Review staff, including statistical reporting, quality audits and inter-rater testing results
Conducting periodic staff meetings with all Oncology Services Clinical Reviewers in their reporting area
Documenting and reporting follow-up of concerns and complaints regarding Clinical Review staff
Assisting in the development and implementation of the annual QM and UM plan and yearly evaluation of clinical manuals
Actively participating in all activities related to accreditation, i.e. URAC, NCQA
Coordinating completion of performance evaluations for Oncology Services team members
Assisting in completion of quarterly audit reporting of Clinical Reviewer activity
Maintaining the confidentiality of patient information in accordance with HIPPA and other regulatory requirements
Assist in completion of appropriate training modules for new and existing Oncology Services Clinical Reviewers
, External Job Requirements:
CareCore National is looking for a licensed Registered Professional Nurse with a minimum of 3 years'' previous supervisory and/or managed care experience with specific knowledge of NCQA, URAC, Medicare and other related industry standards. The ideal candidate will have the ability to independently evaluate and analyze related information in order to plan, develop, and monitor Oncology Services activities to meet Program goals and objectives. Must also be proficient with Microsoft Office, particularly Excel and Word.
Requisition Number: 475
City: Bluffton
State: South Carolina
Job Title: Manager, Oncology Clinical Certifications
Area of Interest: Clinical

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