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Compliance Program Manager III, Precertification for Government Products
3 months ago
Job Summary
The Program Manager is responsible for key departmental functions related to the compliance programs for Medicaid products. Major responsibilities include compliance program development, implementation and performance monitoring and reporting; identifying and proposing strategies to mitigate compliance risks; and direct administration of activities, projects and personnel necessary to ensure compliance with Medicaid laws and regulations governing federal and state contracts for Medicaid products. The Program Manager will be expected to proactively identify program or operational process conflicts and compliance / operations integration issues, and recommend prioritized strategies for resolution. Additional responsibilities include coordination with Corporate Compliance on internal and external audits, and corrective action plans; and working collaboratively with other departments such as Appeals and Grievances, Pharmacy, Customer Relations, the Corporate Compliance (Medicaid) and Privacy Programs, the Fraud Waste and Abuse Unit, and the Internal Audit Department on compliance matters.
Key Responsibilities/Duties – what you will be doing
- Compliance program management. Develop, implement and maintain department's comprehensive compliance program inclusive of performance auditing / monitoring and reporting; corrective action plan development and follow through; policy and procedure creation and revision; staff education; and continuous process improvement activities. Report actual and potential risks for non-compliance to senior manager and lead mitigation planning activities. Provide guidance to senior manager and team managers on regulations to inform operational processes that support UM functions; and to address questions related to individual member coverage requests. Collaborate with Corporate Compliance on regulatory interpretation inquiries. Draft department responses to regulatory inquiries.
- New regulatory guidance. Identify research and disseminate new regulatory guidance. Lead department team, including team managers and staff, to evaluate guidance, prepare a gap analysis, and ensure timely implementation and alignment with department operations. Oversee creation of work flows, training and validation monitoring. Maintain clear "audit trail" documentation of activities to be produced on demand by Corporate Compliance and/or external regulators.
- Audits, monitoring and reporting. Create an "audit ready" department culture. Collaborate with department Senior Manager & Team Managers, Corporate Compliance and other departments to coordinate internal and external audit activities, and internal monitoring and reporting activities. Create and update audit universes using published audit protocols. Review audit / monitoring results and ensure timely communication follow up; and development, implementation and reporting of corrective action plans. Create and maintain documentation of audit / monitoring and performance improvement activities.
- Manages direct reports, both clinicians and non-clinicians as needed.
- Leads and / or represents the department at cross functional meetings as well as interdepartmental meetings as necessary.
Qualifications – what you need to perform the job
EDUCATION: (Minimum) education & certifications required
Bachelor's degree in a clinical / health care related area required
EXPERIENCE: (Years of experience)
- 5 - 8 years related experience in a managed health care environment, with 3 -5 years clinical compliance project/ program management and operational management experience
- 8-10 years of progressive business experience
- 3 - 5 years Medicaid product utilization management experience required
- Medicaid compliance experience preferred
SKILL REQUIREMENTS: (Include interpersonal skills)
- Results orientation -- strives to meet business goals including metric driven targets.
- Highly developed critical and analytic thinking -- must be able to analyze issues, determine root cause analysis and create effective solutions. Must be able to assess impacts of regulator driven changes on department functions and systems, and develop and execute integration strategies that achieve compliance, operational efficiency and support enterprise business priorities. Able to assess staff performance and team operations to problem-solve, drive continuous process improvement and achieve desired outcomes.
- Proven ability to integrate compliance requirements into utilization review operations and clinical system documentation
- Influencing others -- particularly those outside of direct reporting relationships. Ability to lead and motivate team of direct reports (clinicians and non-clinicians) to achieve quality and volume metric targets. Utilize a continuous process improvement approach to evaluate and influence interdepartmental end to end processes that assure administrative efficiency, member satisfaction, and that compliance requirements are met.
- Strong communications skills (formal and informal, written and verbal). Ability to effectively communicate with internal / external business partners & stakeholders at all levels via written correspondence (e.g. e-mail, letters, presentations); and verbally in a clear and professional manner that both meets the needs of the audience and represents the Plan and / or department positively.
- Coaching and Mentoring -- primarily of reports, but also of others. Create and maintain department culture that values and actively supports staff development and supports succession planning. Model professional leadership behaviors and follow company Code of Business Conduct.
- Must have commitment to excellence in customer service that results in positive member and stakeholder feedback.
- Considers creative alternatives to traditional/conventional practices and takes risks within scope of role when appropriate to the situation
- Must be able to prioritize work and manage time to meet deadlines
- Excellent computer skills, including expertise in Microsoft Office Suite: Word, PowerPoint, Excel and Visio
- Ability to develop creative strategies to address problems and overcome obstacles in a rapidly changing, highly regulated environment
- Excellent project management / program management skills
Commitment to Diversity, Equity & Inclusion
Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
Who We Are
Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities.
This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.
Req ID: R7897
