Sales Quality and Compliance Specialist

1 week ago

New York, United States NYC Health Hospitals Full time

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

The Sales Quality and Compliance Specialist reports to the Chief Growth Officer. The Specialist will be responsible for conducting ongoing monitoring activities to ensure the Sales Department's adherence to regulatory and contractual requirements for Marketplace (includes Medicaid, CHP, EP, and QHP), Medicare, MLTC and MAP lines of business.

Job Description

  • Supports the development and review of Sales Department policies and procedures for Marketplace, Medicare, MLTC, and MAP lines of business.
  • Conducts various Growth Division auditing and monitoring activities including field observations. If deficiencies are identified, Specialist will assist in conducting a root cause analysis and implementing corrective actions. Includes administering training for compliance related matters.
  • Conducts audits of Sales Department's adherence and consistency in implementing Policies and Procedures such as but not limited to consistency and quality of Management Oversight of Field Activities (Field Observations, Ride-Alongs, Enrollment Audits, etc.), accuracy of Marketing Schedules and locations, inter-line of business referrals between Enrollment Sales Representatives.
  • Creates and maintains training curriculum and materials, ensuring Sales personnel have access to resources necessary to ensure compliance and regulatory standards are achieved.
  • Thoroughly investigates compliance related issues and regularly report outcomes.
  • Assists in the development and implementation of monitoring metrics used to assess continued compliance with regulatory requirements.
  • Analyzes monitoring metrics to identify trends requiring corrective actions, including coaching, training, and additional monitoring.
  • Collaborates with the Compliance, Regulatory Affairs, Learning & Organizational Development, Sales, Human Resources and Labor Relations to ensure Sales Department objectives and standards are maintained.
  • Creates and maintains Dashboards and tracking tools that provide the Sales Department/Growth Division insight into trends regarding quality, compliance, and regulatory matters within the Growth Division.
  • Conducts audits of systems used within the Growth Division such as Marketplus, Salesforce and MetroPlusHealth links used for application, leads and outreach dispositions for accuracy and completeness to identify anomalies.
  • Spots and takes action via training, reports and other coaching techniques to address application quality regarding cancelation, rejects, voids, rapid disenrollments, pendings, etc.
  • Ensure compliance with NYSOH and CMS rules/guidelines.
  • Supports regulatory implementation activities, including process and policy development and tracking deliverable due dates.
  • Advises Sales Department leaders on compliance-related matters.
  • Participates in meeting, trainings, webinars, and other forums in which existing and new regulatory guidelines are being shared/discussed.
  • Analyzes data to identify areas that impact quality within the Growth Division
  • Maintains accurate and up-to-date records of all Growth Division Training, CAPs, PIPs, and other corrective action documents.
  • Critique bonus/incentive programs within the Growth Division to ensure they are applied according to regulatory guidelines and in compliance with the Bonus Incentive Policy and Procedure criteria by line of business.
  • Ability to synthesize data and produce summary findings reports and presentations for use by the CGO and other members of the Executive Leadership Team regarding Growth Division compliance and regulatory matters.
  • Other duties as assigned or requested.
Minimum Qualifications
  • A Bachelor's degree required
  • At least 4 years of Managed Care experience including thorough knowledge of Medicare, federal, and state regulations
  • Prior experience required in quality improvement and compliance oversight
  • 1-3 years of Compliance/Regulatory Affairs experience
  • Project Management experience
  • Strong computer skills such as Excel, Word, PowerPoint, MS Project
  • Excellent Business Writing Skills
  • Cross-functional interdepartmental skills
Licensure and/or Certification Required
  • CHC, CCEP preferred
Professional Competencies
  • Experience with managed care, Medicare and federal and/or state regulations, quality improvement and compliance oversight.
  • High-level of skill in leading interdepartmental and cross-functional strategy development; experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met. Simultaneously manage multiple projects.
  • Excellent oral, written, and presentation skills, as well as conceptual and analytic skills are necessary in order to review and articulate corporate objectives and Federal regulations across all relevant audiences
  • The utmost integrity in the discreet and confidential handling of confidential materials is necessary
  • Good analytical skills are required
  • Must have excellent writing and presentation skills
  • Critical thinking and process improvement skills are a must
  • Strong interpersonal skills
  • Negotiation skills

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