Resp & Qualifications
Directs and coordinates the activities of the Senior Compliance Review Specialist and Business Analysts. Develops review standards and policies/procedures to assure compliance with required accreditation and regulatory entities and corporate initiatives to mitigate potential risks and financial penalties. Responsible for oversight of compliance activities for the Care Management Division.
Under the general direction of the Director, PreService Review and Compliance, the incumbent’s accountabilities include but are not limited to, the following:
• Oversight and evaluates the compliance activities for the Care Management Division to assure compliance with accreditation and regulatory entities, and corporate initiatives.
• Develops audit work documents reports, and presentations required for accreditation and regulatory reviews and audits.
• Conducts audits, validates audit conclusions and communicates findings and recommendations for improvement or corrective actions for the Care Management Division and external delegated entities.
• Develops educational tools and training programs for regulatory and accreditation compliance requirements for the Care Management Division. Provides ongoing education programs throughout Care Management Division to ensure compliance.
• Responsible for accreditation and regulatory activities such as, but not limited to the preparation of material and reports to acquire or maintain accreditation (such as NCQA, URAC) or to acquire or maintain licensure by the States for three jurisdictions (MD, DC, VA) for the Care Management Division.
• Supervises guides and coordinates the development of reports for the various divisional/corporate committees (i.e. Delegation Oversight, Service Improvement Team, FEP Medical Management Committee, Medical Policy Committee, Care Management Committee, and the Legislation Workgroup).
• Incorporates new standards for state/federal, accreditation agency requirements, and corporate initiatives into Care Management Division work plans.
• Reviews and reports inter-rater reliability testing for accreditation compliance.
• Reviews and edits reports created by associates to ensure accuracy and excellent presentation.
• Analyzes systems and workflows to assure Standard Operating Procedures adhere to compliance and regulatory standards.
• Identifies work processes that may not be in compliance with regulatory requirements or accreditation standards and develops action plans accordingly.
• Identifies opportunities to improve work flows and efficiencies with in the department.
• Prepares proposals for improving work flows and efficiencies for review by management.
• Provides analysis of program and systems’ data for value and accuracy based on experience and clinical expertise.
• Supervises and directs delegation oversight activities to assure compliance with the Delegation Agreements.
• Supervises and directs delegation site audits, analyzes quarterly and annual delegation reports, reviews logs and tracking documentation of all delegated services.
• Coordinates responsibilities for the PreService Review Compliance Supervisor, Senior Compliance Review Nurse Specialists, Business Analysts, and Operation Coordinators and Application Developers.
• Advises the PreService Review Compliance Supervisor on assigning tasks according to associates’ knowledge, skills, experience, and learning needs;
• Provides mentoring and guidance to develop, expand, and improve associates’ skills and expertise;
• Monitors training progress for newly employed associates and training needs for established associates.
• Monitors associates’ daily activities and special assignments
• Assists Director of PreService Review and Compliance with budget for the department area to maintain divisional target.
• Prepares and coordinates Care Management RFP/RFI responses as requested.
Directs and coordinates the activities of the Senior Compliance Review Specialist and Business Analysts and may serve as a matrixed leader for compliance related projects.
Bachelor’s Degree in Nursing is preferred or equivalent experience and 7-10 years of increasingly responsible clinical related experience working in Compliance and Regulatory arena, Care Management, Discharge Coordination, Home Health, or Disease Management; must possess extensive knowledge of how to manage care delivery guidelines and systems. Proven care management experience is critical.
The incumbent must have excellent analytical and problem solving skills, excellent organizational, communication and coordination skills. Must be able to apply complex problem solving abilities to achieve problem and process solutions to evaluate the medical necessity and appropriateness of patient services and treatments, and interface with the multiple internal departments, medical directors and physician practices. Excellent written and verbal communication skills are required. This position requires effective presentation, negotiation and influencing skills to interface with all levels of management and physician practices. The incumbent must be able to apply complex problem solving abilities to achieve problem and process solutions. One year or equivalent in leadership role.
A current DC, MD or VA Registered Nurse license is required.
Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards Previous work experience within CareFirst Care Management. Working knowledge of CareFirst IT and Medical Management systems, familiarity with web based software application environment and the ability to confidently use the internet as a resource. Familiarity with business writing is essential. A master’s in nursing is preferred
Department:Utilization Management and Review
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 4/14/21
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship