Position Description: HMS, Clinical Audit Manager

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Opportunity Snapshot

This position offers you the opportunity to leverage your clinical behavioral health expertise to help lead a newly launched outpatient behavioral health utilization review (UR) audit contract for the Commonwealth of Virginia. You will enjoy the "best of both worlds:" the clinical sophistication of Permedion, a recognized leader in the assessment of healthcare services, and the resources and career growth opportunities of Health Management Services (HMS), our parent corporation, just ranked #3 on Fortune's 2009 FSB 100 list of America's fastest growing small public companies. This home-based role includes a strong degree of flexibility for a professional with a solid sense of accountability and ownership.

You will supervise four clinical auditors working in the field, including scheduling, reviewing reports, and acting as a resource; you also will interact regularly with the client. To be a good fit for this opportunity you will have active and relevant Virginia-recognized clinical credentials (RN, LCSW, LPC, PhD) and solid hands-on clinical experience in behavioral health. Experience with UR and/or audits is preferred but not required. You also will need demonstrated experience in supervising staff as well as a willingness to "roll up your sleeves" when necessary to ensure we meet the contract deliverables.

For 35 years Permedion, an HMS company, has provided external medical peer reviews and independent health care review services for government agencies and large health care providers. Permedion is accredited by URAC in both Independent Review and Utilization Management. Founded in 1985, HMS offers one of the broadest portfolios of service to help government-sponsored healthcare plans recover billions of dollars and save billions more through cost avoidance. While others are cutting back, HMS is growing: our 2008 revenues of $184 million were up more than 20% over 2007, and that rate of growth has persisted through the first half of 2009.

What Else You'll Bring to the Table

In addition to the qualifications detailed above, you'll need:

A bachelor's degree or higher in a health care related field or professionally recognized certification.
Demonstrated high attention for detail.
Solid customer service and client management skills.
Computer literacy and experience with Microsoft Word and Excel.
Strong decision making skills.
Excellent interpersonal and communication skills, including the ability to develop effective relationships with the client and to speak articulately about clinical behavioral health practice.
A self-starter approach and demonstrated ability to achieve goals independently.
Outstanding organizational skills and the ability to manage multiple tasks simultaneously.

Preferred but not required:

Auditing/utilization review experience.
Project management experience.
Familiarity with Virginia regulations regarding outpatient psychotherapy.
Experience with Medicaid or other government programs.

You will work out of your home office and our first preference is that you be based in Richmond, where the client is based. However, you could live anywhere in the Northern Virginia or Tidewater Region as long as you can drive occasionally to Richmond for face-to-face meetings with the client.

What's in It for You

Growing service line -- HMS is proactively expanding its behavioral health program integrity service line and as we grow so will our need for those people with both clinical expertise and demonstrated leadership skills. If you don't already have UR experience, you'll acquire it quickly in this role.

High impact -- this program will take advantage of HMS/Permedion's portfolio of best practices, systems and resources, and will be in operational mode as you come on board. At the same time, you will be able to influence the ongoing growth of this program, including coaching and developing your team as well as refining processes. While you will supervise the four Auditors, your relationship with them will be a "dotted line" on, meaning you won't have to conduct performance reviews or other "solid line" activities.

Clinical sophistication through continuous improvement -- our URAC accreditation requires that we maintain continuous organizational improvement processes, and we never stop learning and growing. This spirit has enabled us to achieve industry recognition for our expertise. For example, we are designated by the Centers for Medicare and Medicaid Services (CMS) as one of eight Qualified Independent Contractors (QIC) in the US, meaning CMS acknowledges that we have the expertise and capabilities to perform appeals of Medicare claims between the carrier and Administrative Law Judge levels.

No signs of slowing -- Medicaid and Medicare budgets are growing (CMS predicts current Medicare/Medicaid spending levels to double by 2015) and, with billions of dollars at stake, there is a strong emphasis among policy leaders (and the voting public) on cost containment and payment accuracy. Permedion and HMS are taking advantage of this climate to drive solid growth. In addition to posting double-digit growth year over year since 2001, HMS is successfully expanding into new markets, including federal healthcare and managed care.

Excellent compensation -- in addition to a competitive salary, we offer a comprehensive benefits package that includes 401(k) plan with generous employer match, flexible spending plans, and much more.

More About Your Role

On July 1, 2009 HMS-Permedion won the contract with the Commonwealth of Virginia Department of Medical Assistance Services (DMAS) to provide behavioral health UR auditing of outpatient psychotherapy providers. We have just transitioned from implementation to production mode. You'll report to the Project Manager who provides the administrative leadership.

You will supervise the Mental Health Auditors, who also have clinical backgrounds, to ensure audit accuracy and timeliness, including monitoring audit decisions, preparing and submitting required reports, and managing assignments and audit workload. These Auditors will work in the field, spending a good deal of time on provider sites; therefore it will be pivotal for you to establish and maintain strong lines of communication. On occasion you may need to perform audits yourself, such as to cover a vacation or emergency absence.

This is a client-facing role and you'll have regular interaction with DMAS, including weekly phone calls and, less frequently, in-person meetings. The goal of these meetings, of course, will be to ensure client satisfaction and manage expectations. In addition, we'll look to you to keep an eye out for opportunities to expand the current contract or provide services in other areas.

In addition to the professionals coming on board specifically for this contract, the program will take advantage of support and resources from other areas of Permedion. For example, our IS department is developing audit applications that will interface with the appropriate databases.

Keys to Success

To excel in this role you will assume ownership of the audit deliverables of this contract and bring a hands-on, action-oriented approach to ensuring delivery to schedule and performance expectations. Driving a young program takes a special kind of leader, one who can combine clinical knowledge, organizational skills, and the leadership and motivational skills to take a team to ever-higher levels of performance.

If this sounds like the right mix of challenge and opportunity for you, and you meet the minimum qualifications, we want to hear from you!

Who We Are

Permedion provides external medical peer reviews and independent health care review services for government agencies and large health care providers, helping them control escalating health care costs while providing appropriate medical care. Our three primary areas of service are health care quality measurement and improvement, data analysis and management, and independent medical review.

With a unique combination of statistical and clinical expertise, Permedion works with government agencies, managed care organizations, and other payors to review, measure and improve health care quality. Our staff includes physicians, nurses, epidemiologists and data analysts, systems experts, and health administration experts. Our partners and customers include health plans, physician groups, government agencies, and professional associations.

Permedion is a wholly owned subsidiary of Health Management Systems, Inc. (HMS), providing clinical expertise to all HMS service lines. HMS is an industry leader in the coordination of program integrity and benefits services for government healthcare programs. Since 1985 HMS has focused exclusively on the healthcare industry and during that time we have partnered with more than 45 Medicaid agencies, other state health programs, and more than 50 government-sponsored healthcare plans to help them recover billions of dollars, and save billions more through cost avoidance. Our portfolio of services includes coordination of benefits for Medicaid-Medicare, third-party liability, and pharmacy services; overpayment recovery; provider audits; medical support enforcement; and more.

We are an equal opportunity employer. EOE M/F/D/V