Key skills
CAnalyticsChange Management
About this role
Role Overview
- Facilitate activities related to performance measurement and outcomes
- Ensure the organization meets CMS, NCQA, and other regulatory standards
- Stay updated on relevant regulatory changes, and support their integration into practices
- Comply with state, federal, and organizational standards by assisting in the development and enforcement of policies aligned with Utilization Management and Compliance requirements
- Complete and successfully submit CMS reports: ODAG, Part C, Reopening, and Complaints and Grievance Reports
- Conduct Root Cause Analysis (RCA) with Operational teams
- Conduct regular compliance audits based on CMS UM standards for expedited, standard and other case statuses
- Develop and guide the implementation of internal audit protocols in compliance with CMS regulations and NCQA standards
- Contribute to the consistency of clinical documentation and decision-making processes
- Generate and validate reports to monitor performance and compliance across health plan contracts, ensuring accuracy and alignment with requirements
- Prepare for regulatory, accreditation, and contractual audits
- Contribute to the remediation and documentation of audit findings
- Perform other job duties as assigned
Requirements
- At least 4-6 years relevant work experience
- Advanced working knowledge of CMS UM audits
- At minimum, 2-3 years of compliance experience focused on CMS and health plan audits
- At minimum, 1-2 years of implementing CMS final rule changes and managing change management of processes
- Bachelor's Degree or equivalent work experience
- Active, unrestricted license: RN, PT, OT or SLP, with a bachelor’s degree in a related field or a combination of education and experience that includes pertinent clinical experience and advanced working knowledge of CMS standards and guidelines
- Experience with NCQA audits
- Must be able to prioritize, plan and handle multiple tasks and demands simultaneously, with competing deadlines
- Excellent in manipulating and sorting data for analytics and reporting
- Prior experience owning client compliance SLAs and ensuring success in meeting SLA requirements
Benefits
- Excellent medical with Rx, dental, and vision benefits
- Mental Health support through EAP
- Generous paid time off, plus 13 paid holidays
- 100% vested 401(K) retirement plans
- Educational assistance up to $2500 per year