Company :Highmark Health
Job Description :
This job supports risk & quality assurance audits required by regulators, the Blue Cross Blue Shield Association (BCBSA), accreditation bodies, executive management, plan partners, group customers, and employee level performance. The programs for which the department is currently wholly or partially responsible for are (a) the BCBSA's Member Touchpoint Measures (MTM), Licensee Desk Level Audit (LDLA), and Federal Employee Program (FEP) Quality Program, (b) the National Committee for Quality Assurance (NCQA), (c) Joint Commission accreditation compliance, (d) quality measures required by state regulators, (e) certain quality measures related to group and partner plan contractual performance guarantees / service level agreements, and (f) employee performance quality.
Completes audit procedures and other assessment activities according to the appropriate framework, (including but not limited to MTM, LDLA, FEP, state, and contractual) in order to identify, assess, prioritize, evaluate and address compliance and other areas of risk. Prepares draft findings, recommendations and other management reporting deliverables. Prepares all work paper and supporting documentation evidence according to audit quality standards in a consistent manner.
Completes audit procedures and other risk assessments in a timely manner in order to ensure compliance requirements are met across the Enterprise. Assists in training and mentoring less experienced team members on multi-faceted engagements, platform customer dependencies, and assists with the review and interpretation of less-complex authoritative guidance.
Assists with the review of inherent risk assessment results and with the development of audit procedures to address relevant risk areas and to ensure proper controls are implemented. Reviews and interprets information provided by third parties (including, but not limited to including but not limited to MTM, LDLA, FEP, state, and contractual) and assists with performing qualitative and quantitative impact assessments.
Assists with preparation of project plans to support risk assessment and risk decisioning processes in coordination with business owners and other stakeholders within task-based budgets. Collaborates with Operations, Sales, Provider and other teams across the enterprise to align risk management objectives, practices and procedures.
Maintains departmental desk-level procedures, assessment methodology, assessment procedures, questionnaires, training, etc.. Reviews and documents activities which demonstrate and support compliance with departmental metrics, performance of internal control activities, awareness of contractual obligations, regulatory requirements, and assistance with responding to customer inquiries / audits.
Interfaces with business areas, technical staff, project teams, and third parties to execute cross-functional risk assurance projects. Prepares materials to support communication of assessment results and findings with multiple stakeholder groups.
Assists with providing input and consultation on risk and assurance requirements. Consults with other areas (e.g., Procurement, Privacy, Information Security, Legal) throughout the engagement lifecycle along with internal and external partners.
Other duties as assigned or requested.
Bachelor's Degree in Accounting, Finance, Business Administration/Management, Information Technology, Pre-Law, or related field
6 years of related and progressive experience in lieu of Bachelor's degree
Master's Degree in Accounting, Finance, Business Administration/Management, Information Technology, Pre-Law, or related field
3 years in Operational Processing or related experience
1 year in Audit and Compliance
LICENSES or CERTIFICATIONS
Certified Public Accountant (CPA)
Lean/ Six Sigma
Demonstrate expert knowledge of business and technology processes, risk and control frameworks, and assessment methodologies, particularly as applied to healthcare (payer and provider) business processes.
Knowledge of relevant regulatory guidelines, vendor management, sourcing and procurement, and completing assessments of vendors
Excellent resource and project planning capabilities, decision making skills, history of results-oriented delivery, and effective team building across a cross-campus and diverse team of management and staff
Strong written and verbal communication skills for diverse audiences (senior management, board, peer, and team)
Strong relationship building skills and ability to influence with and without authority in a matrixed organization
High capacity to think analytically, interpret information / observations, apply judgment and make effective, strategic decision
Language (Other than English):
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
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