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Compliance and Regulatory Expert

2 months ago

Charleston, West Virginia, United States CAMC Health System Full time
Job Summary

The Regulatory Quality Specialist will be primarily responsible for ensuring regulatory compliance and quality needs of the Accountable Care Organization (ACO) across the network and system. This role will be instrumental in the success of the West Virginia Health Network Medicare ACO across new and fast-growing regions of our network.

This position will lead our Medicare risk contracts toward success by excelling across multiple dimensions, including:

  • Developing and implementing strategic plans for growth and operational initiatives that serve our population.
  • Conducting in-depth analyses to generate and implement high-value recommendations.
  • Serving as a reliable policy knowledge expert on evolving Centers for Medicare and Medicaid Services (CMS) programs for the WVHN team.
Key Responsibilities
  • Assist with ACO program oversight and submissions to CMS.
  • Implement and roll out policy and contractual requirements for the Medicare Shared Savings Program (MSSP) ACO.
  • Coordinate activities across operational teams, steering workgroups, and stakeholders.
  • Present findings and recommendations for action to WVHN leadership and meetings, including Board Meetings, and prepare knowledge-sharing presentations on specific topics.
  • Monitor, interpret, and report on changes in performance, market trends, healthcare delivery systems, and legislative initiatives that impact program efforts.
  • Facilitate and operationalize relationships with external organizations, including federal Medicare divisions (CMS and CMMI) and community strategic partners.
  • Interface with regulators to participate in and report back on program meetings, track and obtain responses on program questions, etc.
  • Analyze quality, utilization performance by provider, practice, region, payer, and in the aggregate to inform contract performance and identify whether improvement efforts have impacted performance.
  • Collaborate with the IT regulatory program manager to understand and accomplish needs of the ACO.
  • Identify gaps and barriers that may impact shared savings and other payer reimbursement.
Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact): The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment, or care as defined by the department's identified patient ages.

Specifically, the employee must be able to demonstrate competency in:

  • Ability to obtain and interpret information in terms of patient needs.
  • Knowledge of growth and development.
  • Understanding of the range of treatment needed by the patients.

Competency Statement: Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department-specific competency checklist.

Common Duties and Responsibilities
  • Maintain and document all applicable required education.
  • Demonstrate positive customer service and co-worker relations.
  • Comply with the company's attendance policy.
  • Participate in the continuous, quality improvement activities of the department and institution.
  • Perform work in a cost-effective manner.
  • Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
  • Perform work in alignment with the overall mission and strategic plan of the organization.
  • Follow organizational and departmental policies and procedures, as applicable.
  • Perform related duties as assigned.
Education
  • Associate's Degree (Required)

Understanding of healthcare payer programs, quality management, analytical skills, project management, compliance audits, facilitation, performance improvement.