Health Management Systems, Inc. Nurse Clinical Specialist - Case Management - Remote in TX, Texas
HMS makes the healthcare system work better for everyone. We fight fraud, waste, and abuse so people have access to healthcare—now and in the future. Using innovative technology and powerful data analytics, we help government and commercial payers reduce costs, increase quality, and achieve regulatory compliance. We also help consumers take a more active role in their own health. Each year, we save our clients billions of dollars while helping people live healthier lives. At HMS, you will develop new skills and build your career in a dynamic industry while making a difference in the lives of others.
We are seeking a talented individual for a Clinical Specialist who provides clinical subject matter expertise to the Clinical Policy Team. Primary responsibilities include: develop clinical content standards, liaison with Clinical Services team, maintain expertise in HMS clinical review products and processes, SME support for account management and sales teams, internal and external education on clinical programs, identify and remediate performance gaps in HMS clinical programs, develop new ideation and concept briefs for HMS clinical programs.
Work in conjunction with the physician team to develop and document clinical content standards. Identify best practices in the company or industry and use in standard development. Clinical content standards will drive clinical decision making and documentation for the Clinical Services, Quality and Appeals teams.
Work with HR, Training and Education teams to make sure that clinical content standards are well understood by all levels of the organization.
Liaison with leadership of applicable departments to assure that clinical content standards are the basis for decision making and documentation performed by the operational teams.
Maintain expertise in current HMS clinical program processes, work flows and outcomes
Provide primary SME support regarding HMS clinical policy, clinical review programs and processes to account management and sales teams for both State and Health plan clients.
Meet with clients to explain programs and processes, discuss concerns, identify issues and develop proactive solutions to problems that clients may be having or anticipate having with HMS clinical review programs.
Participate in review and analysis of existing HMS clinical review programs; identify performance gaps and assist with developing plan to improve program performance
Generate ideas for new ideation, assist with developing review concepts, concept briefs and scoping analysis and documentation as assigned.
Support provider centric delivery on HMS programs and policies
Assist in developing clinical content for HMS clinical acquisition programs and provide assistance as needed in acquisition integration
Support industry awareness of HMS as clinical leaders, writing white papers, preparing and/or delivering conference presentations, etc.
- Performs other functions as assigned
Knowledge, Skills, and Abilities:
Familiar with principals of clinical audit, utilization review and payment integrity programs.
Familiar with federal and state regulations and payment integrity industry standards
Experience with HMS clinical claims review program processes, work flows and outcomes
researching federal and state regulations as well as industry standards from a variety of sources
Excellent verbal and written communication skills.
Ability to comfortably present HMS programs to client leaders and staff
Work Conditions and Physical Demands:
Primarily sedentary work in a general office environment
Ability to communicate and exchange information
Ability to comprehend and interpret documents and data
Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
Requires manual dexterity to use computer, telephone and peripherals
May be required to work extended hours for special business needs
May be required to travel at least 10% of time based on business needs
- Bachelor’s Degree or 10 years of experience in lieu education and experience
- Required Nursing license, Coding certificate, or other licensed clinical professional
Minimum Related Work Experience:
7-9 years of experience with a combination of the following:
experience in the healthcare field as a nurse/clinician
experience in one of the following areas:
Client service/business to business,
Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.
Title: Nurse Clinical Specialist - Case Management - Remote
Requisition ID: 19001014