Quality Control Senior Manager

Quality Control Senior Manager

Do you have the career opportunities as a Quality Control Senior Manager you want with your current employer? We have an exciting opportunity for you to join HCA Healthcare which is part of the nation's leading provider of healthcare services, HCA Healthcare.

HCA Healthcare offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include : comprehensive medical coverage, additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans, auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance, and more. Free counseling services and resources for emotional, physical and financial wellbeing, 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan with 10% off HCA Healthcare stock, family support through fertility and family building benefits, referral services for child, elder and pet care, consumer discounts, retirement readiness, rollover assistance services, preferred banking partnerships, education assistance, colleague recognition program, time away from work program, and Employee Health Assistance Fund. Note : Eligibility for benefits may vary by location. Our teams are a committed, caring group of colleagues. Do you want to work as a Quality Control Senior Manager where your passion for creating positive patient interactions is valued? If you are dedicated to caring for the well-being of others, this could be your next opportunity. We want your knowledge and expertise!

Job Summary

We are seeking a diligent and experienced Senior Manager, Clinical Review, Quality Control to ensure the quality and accuracy of clinical reviews. This role is pivotal in identifying and addressing payer medical policy issues, supporting the regulatory compliance team, and enhancing the overall quality of our clinical processes. The Senior Manager will analyze physician documentation, assist with quality control and oversight, and serve as a subject matter expert for educational programs. This position also involves active participation in leadership meetings and contributing to the onboarding of new physician advisors.

Major Responsibility

Perform rigorous quality control on clinical reviews, focusing on patient status, level of care, and length of stay to ensure accuracy and compliance. Proactively identify and address payer medical policies that lead to inappropriate denials, advocating for fair and accurate coverage. Provide crucial support to the regulatory compliance team in managing appeals and improving documentation to meet regulatory standards. Serve as a subject matter expert, guiding clinical appeal and peer-to-peer processes with expertise and insight. Actively participate in leadership meetings, contributing to strategic decision-making, and assist in the onboarding of new physician advisors, ensuring they are well-prepared for their roles. Conduct thorough quality control on accounts that have been reviewed, specifically focusing on patient status, level of care, and resolution of length of stay disputes. This includes assessing inpatient vs. outpatient observation status and ensuring compliance with the two-midnight rule. Respond promptly to requests for intervention from the centralized peer-to-peer team and others regarding denials and appeals processes, observation level of care, decisions about admission, patient transitions, and other situations as needed. Analyze and monitor physician documentation to pinpoint areas needing improvement, ensuring comprehensive and accurate records. Support regulatory team members by highlighting accurate clinical documentation in appeals to substantiate the medical necessity of provided services. Serve as a subject matter expert, coordinating ongoing educational programs to strengthen clinical appeal and peer-to-peer processes. Bring potential or actual problems in physician practices or documentation to the attention of regulatory leadership, ensuring timely and effective resolution. Assist with the onboarding of new physician advisors, providing guidance and support to ensure their success. Function as a key member of the executive management team, participating in leadership meetings and contributing to strategic initiatives.

Education & Experience

A minimum of 8-10 years of clinical experience is required. At least 2 years of leadership experience is preferred. Possess a strong clinical background, with preference given to candidates familiar with Medicare and Medicare Advantage's Two-Midnight Rule. MD / DO preferred, particularly those no longer directly involved in patient care.

We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.