Duties Manages a team to oversee all phases of Enterprise, Network, and Plan Partner performance related to an assigned scope, including helping to research and distill requirements into actionable form and set performance standards, performing proactive gap and risk analyses, developing and monitoring metrics to track ongoing fidelity to these requirements, analyzing and reporting results to Leadership, and collaborating to take corrective action to remediate issues of non-compliance.
Responsible for maintaining documentation to support evidence of compliance with all requirements, for the reporting of performance data, and for auditing all delegated entities.
Reviews policies and procedures (PPs), internal controls, and processes to identify gaps and opportunities for improved performance and to ensure that client, its Plan Partners, Network, and vendors demonstrate adherence to applicable requirements in timely updated PPs, workflow(s), and other artifacts.
Oversees team efforts to partner with the functional business leaders, Compliance, Legal, and Quality Improvement to coordinate responses to regulatory inquiries and actions, and to the NCQA, and assists in preparing for and responding to internal and government audits examines audit findings and collaborates to respond to cited deficiencies and monitors implementation of corrective action plans.
Proactively informs the organization, senior Leadership, and relevant committees, including the Internal Compliance Committee (ICC) of possible risks and issues with sub-optimal internal and external criteria-based performance, and develops remediation and corrective action plans, as appropriate.
Manages assigned staff, including, but not limited to monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues raised by staff.
Encourages staff to provide recommendations for relevant process and systems enhancements, among others.
Performs other duties as assigned.
Experience Minimum of 5-7 years of experience in risk management andor contract andor regulatory andor accreditation requirements analysis in managed care or other related health care industry.
At least 3-4 years of supervisorymanagement experience.
Minimum of 5 years of experience in Healthcare Compliance, Risk Management, Legal, or related field, in a complex and high-demand business setting.
Required Demonstration of both qualitative and quantitative analytical skills.
Proven ability to work with a diverse group of people, including external entities, physicians, support staff, coworkers and management.
Demonstrated ability to research issues and bring about resolution either directly or with the assistance of others.
Demonstrated critical thinking and problem solving skills.
Strong written and verbal communication skills.
Strong elicitation and process documentation skills.
Strong organizational and communication skills to build and foster effective relationships.
LicensesCertifications Preferred Certified HealthCare Compliance (CHC) Certified in Healthcare Compliance Fellow (CHC-F) Certified Compliance Ethics Professional (CCEP) Education Required Bachelor’s Degree In lieu of degree, equivalent education andor experience may be considered.
Education Preferred Juris Doctor Degree or Doctor of Law Degree (J.D.) Master’s Degree in Public Health or Related Field