This position will perform a range of duties including, but not limited to, evaluating all current and new compliance regulations, reviewing company policies and procedures, provide subject matter expertise and performing internal audits. The successful candidate will be able to multi-task and be an excellent communicator, with in-depth knowledge of the latest industry trends and regulations.
Responsibilities:
- Keep abreast of regulatory developments within or outside of the company as well as evolving regulatory landscapes and best practices in compliance programs
- Ensure our product solution is compliant with applicable requirements (i.e. Medicare, NCQA) by notifying internal teams of regulatory changes and working with them to develop requirements for enhancements
- Educate and communicate verbally and in writing to leadership, impacted staff and current/new clients on any new or changes to regulations
- Facilitate internal audits as well as perform mock audits using CMS audit and Corrective Action Plan (CAP) protocols
- Assist clients with CMS audit preparation, as well as provide action oriented detailed feedback
- Ability to work with new clients during implementation to ensure no compliance issues are identified
- Ensure product content, workflow and SLAs meet client, regulatory and accreditation requirements
- Conduct platform testing as part of the software development life cycle to ensure compliance prior to release
- Identify key stakeholders and assist in RCA process to ensure RCAs are completed and delivered timely
- Ensure any corrective action plans are issued and tracked to completion
- Able to adapt to competing demands, take on new responsibilities, and adjust schedule to meet changing priorities
- Monitor internal compliance programs on an ongoing basis and ensure modules are compliant with the most current regulatory body requirements, keeping privacy practices in place and remaining fully compliant.
- Update client monthly steering decks with all applicable changes and notifications for the month, verbally communicate these changes in client meetings
Requirements:
- Five years’ experience at a health plan, with proven Managed Care experience
- Proven Management experience in a compliance role with regulatory reporting experience
- Strong knowledge of CMS/Health Plan processes and regulations is required
- Experience with regulatory reporting, ODAG, CDAG, and NCQA
- Outstanding communication and interpersonal abilities
- An analytical mindset with exceptional organizational skills
- Firsthand experience with health plan operation sin utilization management, appeals, grievances, pharmacy and or case management
- Methodical and diligent with outstanding planning abilities
- An analytical mind able to “see” the complexities of procedures and regulations
- Experience researching and summarizing applicable regulatory requirements
- Ability to write updates and memos to C-suite level internal and external clients
- Superb written, verbal communication and interpersonal skills
- Excellent in the use of Microsoft applications
Education Requirement:
Bachelor’s Degree - Associates Degree or relevant work experience