2 jobs found in Hybrid

COMPLIANCE SPECIALIST Under the general supervision of the Vice President of Compliance & Privacy Officer, the Compliance Specialist is responsible for conducting investigations and audits related to fraud, waste, and abuse within the DWIHN provider network. This role includes performing targeted reviews, gathering and analyzing information, and applying relevant regulations, policies, and internal controls to assess compliance. The Compliance Specialist also supports the implementation of policies, procedures, and control measures to ensure that DWIHN and its providers adhere to applicable regulatory and ethical standards.   PRINCIPAL DUTIES AND RESPONSIBILITIES: Conduct FWA Investigations:   Manage investigations related to suspected fraud, waste, and abuse within the provider network. Data Gathering & Analysis:   Collect, review, and analyze relevant documents, data, claims, medical records, and other evidence to assess compliance...

CLINICAL SPECIALIST  The Clinical Specialist will provide therapeutic support, crisis intervention, clinical assessments, and evidence-based therapeutic interventions. This Clinician also delivers a person centered and goal-oriented approach to individuals experiencing acute mental health crises.   PRINCIPAL DUTIES AND RESPONSIBILITIES: Conducts electronic case reviews. Authorizes treatment plans. Provides consultations utilizing medical necessity criteria. Evaluates clinical appropriateness. Monitors provider treatment plans to ensure quality and effectiveness of service. Performs data gathering, documentation and analysis for desired outcomes. Advocates for clients to ensure treatment needs are met. Follows guidelines of the integrated care case management program with respect to identifying and assessing clients, developing and managing the treatment plans, and facilitating complex care arrangements. Performs initial and ongoing review of...