Director, Quality

3 weeks ago

Boston, United States Commonwealth Care Alliance Full time

**Why This Role is Important to Us**:
**Position Summary**:
The Director, Quality & Control Assurance reports to the VP of Quality & Control Assurance is responsible for providing strategic leadership and oversight for the Quality & Control Assurance within CCA’s Compliance department. This position designs, continually matures, promotes, & develops a program that adheres to all applicable federal, state, and contractual requirements.

This position and is responsible for designing quality and control assurance reviews of claims, Hierarchical Condition Categories (HCC) and clinical coding, call monitoring, system technology upgrades, and other critical compliance/financial/operational controls and processes across the CCA enterprise, including all health plan and care delivery activities. These responsibilities include planning, executing, and evaluating results of quality audits/reviews and control/operational integrity initiatives, evaluating error patterns and trends, and ensuring the reporting of relevant quality audit/review results, call monitoring reviews, and evaluation of HCC audits/reviews, among others, to relevant departments.

The role also leads the department’s focused review and internal controls assurance; SOX/SOC/MAR (Model Audit Rule) testing/assurance; technology/systems assurance; external and regulatory audit management, support, and facilitation; and CAP remediation teams. The role and department evaluate statistical patterns and trends of quality and controls assurance results and collaborate with owners of audited/reviewed business areas to address root causation of errors and facilitate overall quality improvement.

**Supervision Exercised**:
Yes, which includes but is not limited to providing leadership, work direction, and performance feedback to subordinate staff.

**What You'll Be Doing**:
**Essential Duties & Responsibilities**:

- Under the guidance of the VP, Quality & Control Assurance assist with providing strategic leadership and oversight for the Quality & Control Assurance within CCA’s Compliance department.
- Designs, builds, develops, assesses, and adapts clear and effective Quality Assurance and controls monitoring, audits/reviews, testing, reporting, and audit sampling methodologies to ensure proper, effective, and timely assessments. Conducts regular assessments of existing quality audit protocols, activities, and reports; develops new protocols as necessary; and facilitates effective remediation of findings and corrective actions. Updates and ensures protocols and controls are followed, including timely completion of quality audits/reviews and controls assurance assessments.
- Develop, maintain, revise, and ensure accuracy of Quality & Control Assurance policies & procedures, SOPs, risk assessments, and work plans.
- Provides clear and effective reports to the relevant business, functional and operational areas, as well as other internal/external stakeholders, regarding quality audit/review findings, contractual requirements, industry standards and best practices.
- Conducts regular and ongoing risk-based evaluation of new quality audit/review opportunities and conducts regular evaluation of the methodology and relevance of existing audits. Oversees and directs regular gap analyses, risk assessments and program effectiveness assessments for the different Quality & Controls Assurance programs and functions.
- Establishes and ensures quality standards by designing effective quality audits/reviews and controls assessments and selecting the most appropriate and effective sampling methodology to test quality on audited samples.
- Ensure maximum productivity on all quality audits/reviews and controls assessments, which provide management and leadership with timely, effective, and valuable feedback. Analyze, evaluate, and present information concerning relevant factors, such as business scenarios, production capabilities, and design and development of department workflows. Maintain databases, dashboards, scorecards, and reports of production, statistical, operational, and financial results.
- Responsible for Quality & Controls Assurance programs, activities and reviews, including claims reviews; call center and digital communications reviews; Medicare Risk Adjustment, HCC, clinical and coding reviews; DRG and medical records reviews; technology/systems and coding upgrade and implementation reviews (e.g. final user acceptance testing, etc.); Government Programs product compliance reviews; operational reviews (e.g. enrollment and eligibility, ID cards, premium billing, EOBs, coordination of benefits, etc.); select vendor reviews; product-specific samples and reviews; focused review and internal controls testing and assurance; SOX/SOC/MAR testing and assurance; external and regulatory audit management, support, facilitation and reporting; CAP remediation oversight, support, facilitation and reporting; and GRC tool/solution, technology and data analytics implementation

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