Ensures all Care Management (Health Services, Utilization Management, and Case/Disease Management) activities are compliant with the regulations and standards that govern our industry. Provides guidance and oversight to the departments within Health Services regarding the requirements of accrediting and regulatory agencies, including but not limited to the Centers for Medicare and Medicaid, state Medicaid organizations, and NCQA. Leads a team of associates who monitor compliance through business monitoring audits, staff performance quality audits, surveillance and defect reports, and provides systemic report and education opportunities to departmental leaders and associates.
Reports to: VP, Care Management & LTC
Location: Tampa, FL (Henderson Rd)
- Ensures all UM. CM, DM and other HS operational processes are compliant with NCQA standards, as well as state/federal contract guidelines.
- Coordinates with Regulatory Affairs in each line of business to ensure that corporate policy and addendums are compliant.
- Coordinate monthly and quarterly audit and business monitoring results to provide systemic results and highlight opportunities for improvement.
- Coordinates with the Training team to ensure that training curriculum supports operational processes as defined in P&Ps.
- Coordinates schedules for review and revision of P&Ps with HS Corporate Development and Shared Services Teams.
- Develops audit programs to ensure compliance with all operational processes.
- Reports audit results to management team and respective market leadership.
- Leads UM, CM, DM and other HS teams' operational departmental responses to individual market EQRO/State and CMS audits.
- Oversees prep of files for respective external audits.
- Provides feedback to UM, CM, DM leadership team regarding audit results, opportunities for improvement, and/or required CAP.
- Manages the UM, CM, DM Compliance team.
- Oversees Monitoring Teams responsible for research, education and conducts audits.
- Provides Compliance team performance reports to appropriate leadership representatives.
- Performs special projects as assigned.
- A Bachelor's Degree in a related field such as Business Administration, Legal, Political Science or related field is required
- A Master's Degree in a related field is preferred
- 10 years of experience in in a regulatory, compliance or oversight function is required
- 5 years of management experience is required
- 4 years of experience in Healthcare delivery; manage care preferred is required
Licenses and Certifications:
- Demonstrated problem solving skills Independent problem solving to overcome barriers and meet deadlines
- Ability to work within tight timeframes and meet strict deadlines
- Ability to lead/manage others
- Demonstrated analytical skills
- Ability to work in a fast paced environment with changing priorities
- Demonstrated written communication skills
- Demonstrated interpersonal/verbal communication skills
- Knowledge of community, state and federal laws and resources
- Other Ability to interpret contract and regulatory language
- Other Ability to communicate on any level required to meet the demands of the position
- Other Ability to identify and remedy business issues through process improvement methodologies - Six Sigma, Lean, etc.
- Preferred Licensed Registered Nurse (RN)
- Intermediate Microsoft Excel Proficient in Microsoft Outlook applications, including Word,Excel, Power Point and Outlook
- Intermediate Microsoft Word Ability to use proprietary health care management system
- Intermediate Microsoft Outlook
- Intermediate Microsoft PowerPoint
- Intermediate Microsoft Visio
- Intermediate Healthcare Management Systems (Generic)