Lead Claims Analyst

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.

Best People, Best Solutions, Best Results

Job Summary:

Qlarant, a leader in healthcare quality and compliance solutions, is currently seeking a highly skilled and experienced Supervisor - Nursing. This position will play a pivotal role in ensuring the optimal performance of our medical review division by continuously monitoring and analyzing performance metrics to identify and implement process improvements. The successful candidate will assist and support the Director - Medical Operations in managing operations and administration of contracts, and oversee the day-to-day activities of clinical teams. A key responsibility includes supervising teams to ensure compliance with relevant laws, regulations, and organizational policies, and collaborating inter-departmentally to prioritize compliance efforts and address regulatory requirements. The role demands a proactive approach to mitigate potential risks to program integrity and to maintain and enhance the quality of nursing activities in line with established standards and guidelines.

The Supervisor - Nursing will also engage with governmental and law enforcement stakeholders as required and independently assess nursing processes for efficiency, effectiveness, and compliance. Collaboration with other departments, stakeholders, and external entities is crucial to ensure a comprehensive approach to program integrity and patient care. The incumbent will work closely with the Supervisor - Clinical Review's staff to manage workload, ensuring timeliness and quality of service delivery. Maintaining accurate documentation of nursing program activities and producing regular reports on metrics related to program integrity, compliance status, and quality is expected. Instructing nursing staff on compliance and integrity matters, ensuring they understand and adhere to policies and procedures, and providing job-specific orientation and training as needed are also responsibilities of the Supervisor - Nursing. Managing team performance through regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development is a critical aspect of the role.

Essential Duties and Responsibilities:

• Supervises teams to monitor and ensure compliance with relevant laws, regulations, and organizational policies. Collaborates inter-departmentally to prioritize compliance efforts and address regulatory requirements.
• Implements measures to mitigate potential risks to program integrity.
• Ensures best practices are followed to maintain and enhance the quality of nursing activities, ensuring they meet established standards and guidelines.
• Engages with governmental and law enforcement stakeholders as required.
• Acts independently to assess existing nursing processes for efficiency, effectiveness, and compliance.
• Collaborates with other departments, stakeholders, and external entities to ensure a comprehensive approach to program integrity and patient care.
• Works closely with the Supervisor - Clinical Review's staff to manage workload, ensuring timeliness and quality of service delivery.
• Maintains accurate documentation of nursing program activities and produces regular reports on metrics related to program integrity, compliance status, and quality.
• Instructs nursing staff on compliance and integrity matters, ensuring they understand and adhere to policies and procedures. Provides job-specific orientation and training as needed.
• Manages team performance through regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development. Provides job specific orientation and training when called upon.

To perform the job successfully, an individual should demonstrate the following competencies:

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  Business Expertise- Good understanding of how the team integrates with others in accomplishing the objectives of the department.
  
  
  
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  Problem Solving- Uses judgment based on practice and precedence.
  
  
  
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  Nature of Impact- Direct impact by ensuring the quality of the tasks/services/information provided by self and others.
  
  
  
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  Area of Impact- Primarily on closely related work teams.
  
  
  
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  Interpersonal Skills- Developed communication skills to exchange complex information.
  
  
  
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  Leadership- Allocates work as a team leader; may check on completion/quality.
  
  
  
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  Functional Knowledge- Good understanding of concepts and procedures within own discipline and basic knowledge of these elements in other disciplines.
  
  
  
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  Project Management- Lead project/program team member checking the work of others. Typically responsible for training and developing new team members.
  
  
  

Education (education can be substituted for experience):

• Minimum Bachelor's Degree
• Current, active and non-restricted RN licensure required.
• Coding certification preferred.

Work Experience (experience can be substituted for education)

• Minimum of 5-7 years experience
• Minimum of 8-11 years experience preferred

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.