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What is your impact:
The Clinical Accreditation and Regulatory Consultant provides oversight of clinical decision making for Florida Blue and third-party entities delegated for utilization management (UM) functions for Medicare Advantage lines of business. The incumbent will evaluate operational effectiveness of processes and related controls supporting clinical decision-making for both internal areas as well as external business partners. This role will ensure adherence to CMS guidelines and requirements and serve as clinical resource in CMS oversight and audit preparedness activities. This role is responsible for issuing results of oversight activities and findings to senior and executive level leadership at Florida Blue and delegated entities via monthly reports and presenting results at the Delegation Oversight Committee as applicable. Additionally, the role will be responsible for ensuring timely closure of noted issues and completion of validation activities.

What are the key responsibilities
Design and administer clinical audit programs for various external business partners (i.e. Vendors).
Collaborate with Florida Blue Internal Audit Compliance team, Medical Directors, Vendor Representatives, and Senior Management to help drive adherence of Medicare Advantage regulatory requirements within FB and various Vendor clinical departments.
Prepare monthly audit findings report for Senior and Executive Leadership with minimal oversight
Conduct monthly meetings with Clinical Review and Vendor Management leadership
Coordinate and Conduct Oversight of Appeal Overturns
Research CMS.gov and related industry publications for updates and changes to guidelines and effectively communicate to the appropriate departments and vendors

What is required:
5+ years related work experience. Experience Details: Conducting file audits and managing projects
RN - Registered Nurse - State Licensure And/Or Compact State Licensure Florida Licensed Registered Nurse
Experienced with CMS guidelines and compliance
Experienced with FB medical coverage guidelines and Interqual
Proficient in Excel and Microsoft Office Suite FB UM and Claims System knowledge

What is Preferred:
Researching the Internet and CMS.gov
Experience with NCQA

General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally

What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
Medical, dental, vision, life and global travel health insurance;
Income protection benefits: life insurance, Short- and long-term disability programs;
Leave programs to support personal circumstances;
Retirement Savings Plan includes employer contribution and employer match;
Paid time off, volunteer time off, and 11 holidays
Additional voluntary benefits available; and
A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Salary Range: $72,300. - $117,500
Typical Annualized Hiring Range: $72,300 - $90,400

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive, and equitable culture for our employees and communities.