Clinical Operational Compliance Director
3 weeks ago
Job Summary:
The Director of Clinical Operational Compliance will lead the design, implementation, and monitoring of existing workflows and state and federal legal, regulatory, and compliance updates within the Clinical department. This role will collaborate with the Vice President of Clinical Operations and Performance and the SVP, Legal and Regulatory Affairs and Compliance (LRAC) to ensure compliance with regulatory requirements.
Key Responsibilities:
- Design and implement operational legal, regulatory, and compliance monitoring within the clinical department
- Work with business owners to put in place regular risk assessment and effective implementation and oversight of risk mitigations
- Develop processes in consultation with appropriate Directors in LRAC
- Perform and/or collaborate with LRAC and other business teams to conduct internal readiness audits of individual business areas or prepare for external audits
- Engage expert resources, as needed, to supplement internal abilities
- Identify gaps and work with business owners to prioritize and address
- Create regular reporting of key metrics to monitor performance
Additional Responsibilities:
- Oversee clinical operational compliance activities
- Identify implementation and compliance risk, actively document and propose and oversee implementation of corrective action and remediation with goal of minimizing compliance issues
- Ensure required deadlines are met across the clinical department
- Collaborate with business owners to prevent compliance issues
- Successfully prepare clinical team for internal and external audits
- Strategically address compliance-related issues as they arise
- Recommend policies and work with business owners to implement
- Oversee activities related to compliance for clinical vendors
- Ensure proper compliance reporting for clinical department for EOHHS, DOI, GIC CMS, and other groups as required
- Participate in audits and meetings, as required, with CMS, DOI, and other regulators
- Oversee organization determination appeals and grievances for part B and coverage determination appeals and grievances for part D
- Monitor delegated vendors for clinical criteria updates and track implementation of changes
- Build strong customer relationships and meet customer expectations
- Collaborate with other members of the clinical team to provide a seamless experience for members and MGB HP staff
- Provide reports to senior leadership on compliance functions and readiness
Requirements:
- Bachelor's degree required or the equivalent combination of training and experience, plus 5-7 years related experience
- Three years health care compliance-related experience required
- Three years leadership experience required
- Medicare Advantage experience required
- Valid unrestricted RN or another clinical licensure in Massachusetts preferred
- Master's degree in health care or business administration preferred
Skills and Abilities:
- Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value
- Bring fresh ideas forward by listening to and working with employees and the people we serve
- Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner
- Strong, demonstrated track record of an ability to execute on time, on budget, and on scope
- Strong aptitude for technology-based solutions
- Ability to inject energy, when and where it's needed
- Current in healthcare trends
- Demonstrated forward, visionary thinking; ability to see 'what is' and envision 'what could be'
- Ability to develop, introduce, defend, and gain support for new ideas and approaches
- Excellent leadership skills and leadership track record
- Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills
- Ability to view the long-range trends and cycles of the business and industry and see the 'big picture'
- Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions
- Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy
- Excellent interpersonal skills, including the ability to influence others at all levels of an organization
- Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback
- Unquestionable integrity
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