Gateway Health Plan
Job Description :
I. GENERAL OVERVIEW:
Partner with business units to ensure compliance to rules, regulations, policies, and procedures of governmental, contractual, and/or corporate entities. Provide consultation and analytic support to assigned functional areas. Continuously monitors regulatory changes, legislative efforts, industry trends, and/or contract changes.
1. Manage and coordinate compliance related processes.
2. Monitor governance and compliance of rules, regulations, policies, and procedures and assist with appropriate audits, as applicable. Contacts may include legislators, consumers, special interest groups, advocacy agencies, CMS and other regulatory bodies such as DPW.
3. Ensure systems are updated and accurate for compliance.
4. Responsible for understanding and applying accreditation and regulatory requirements. May support Regulatory Compliance department to ensure all state renewals, applications, and annual reports are completed accurately and timely.
5. Depending on department may be responsible for one of the following: the delegation oversight of subcontractors when applicable to ensure compliance with health plan standards and policies and regulatory bodies; performing and providing oversight of the care management delegation functions of multiple vendors through review of annual assessments, monthly performance reporting and analysis of reports to ensure adherence to regulatory and accreditation standards.
6. Other duties as assigned or requested.
Education, Licenses/Certifications, and Experience (For Experience requirements please see appropriate role/level guide. If not applicable, list experience requirements below.)
- Master’s Degree preferred
- Experience in one or more of the following: healthcare operations, compliance, auditing, investigations, regulatory accreditation, process improvement, project management and/or managed care operations
Knowledge, Skills and Abilities
- Strong written and oral communication skills.
- Strong customer orientation with excellent interpersonal skills, including interview techniques, good judgment, initiative, and discretion in confidential or sensitive matters.
- Self-starter with the ability to work under pressure independently and as part of a team.
- Superior decision-making abilities under a variety of circumstances and creative thinking and effective risk mitigation abilities.
- Strong process improvement and project management skills.
- Strong analytical ability.
- Demonstrated ability to effectively interact with all levels within the organization.
- Proficiency with Microsoft Office software programs and database query tools, and other Internet and Intranet applications and databases.
IV. SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? No
Is Travel Required? Yes
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.
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