Care Management Compliance Manager

Principal Duties and Responsibilities

Implement operational legal, regulatory and oversight within the care management teams.

• Monitoring and Evaluation of end-to-end care management activities
• Facilitate the implementation of routine monitoring tools for ongoing monitoring of clinical adherence to CMS and State-specific requirements
• Conduct standard qualitative and quantitative chart reviews in accordance with established procedures for monitoring of adherence to contractual requirements
• Perform and/or collaborate with LRAC and other business teams to conduct readiness audits
• Identify gaps and work with business owners to prioritize and address

Evaluate care management operational compliance activities to drive performance improvement.

• Evaluation of end-to-end care management activities related to compliance
• Timeliness of contractually required services
• Service plan/ plan of care execution and documentation to state requirements
• Lead the development of reports to drive risk mitigation and or improvement action plans
• Communicate best practices, barriers, opportunities, and potential solutions to stakeholders
• Supports care management on process development and improvements related to regulatory changes and any remediation activities for CAPs, etc.

• Acquire and maintain detailed knowledge of federal and state compliance regulations (e.g. mental health parity)
• Maintain knowledge of other industry requirements (e.g. NCQA) and communicate connections to business leaders between industry bodies and regulators
• Function as Subject Matter Expert of clinical contractual requirements
• Facilitate communication between the designated teams and functional SME's
• Consult with Regulatory Adherence/HP compliance to meet applicable rules and regulations
• Recommend additional key resources needed to meet project goals

• Works in partnership with Learning & Development for proactive development and delivery of training on opportunities identified from oversight activities
• Identify knowledge gaps and areas of growth opportunities within the care management department
• Partner with clinical training resource(s) to ensure training meets regulatory and contractual standards and aligns with operational policies and procedures

• Participate in the development, review, and implementation of policies, procedures, and job aids to ensure operational compliance across documents and operations
• Collaborate with LRAC on the annual review process for care management documents

• Bachelor's Degree required;
  Master's Degree preferred

• Unrestricted RN license in state of residence

Required

• At least 3-5 years of clinical experience in a healthcare setting, with a focus on compliance and regulatory requirements required

Preferred

• At least 5 years of clinical nursing experience strongly preferred
• At least 2 years of Medicare, Medicaid, and DSNP Managed Care Experience strongly preferred
• At least 2 years of experience with contract interpretation/compliance strongly preferred
• Master's degree and or managed care experience at the management level preferred
• Knowledge of NCQA standards and CMS, & DMHC regulations
• Knowledge of Quality Improvement philosophy and techniques
• Knowledge of Medicare Local Coverage Determination, National Coverage Determination and MCG/Inter Qual criteria
• Understanding of Project Management
• Management or supervisory experience preferred.
• Knowledge of ICD-10-CM, CPT, and HCPCS codes

• In-depth knowledge of healthcare laws, regulations, and standards related to clinical practices.
• Strong analytical and problem-solving skills.
• Excellent communication and interpersonal skills.
• Proven experience in developing and implementing clinical compliance programs.
• Detail-oriented with the ability to interpret and apply complex regulatory requirements.

• Proficiency in all Microsoft Office Programs
• Experience in data analysis.
• Proven ability to identify operational process gaps and clinical gaps in care.
• Experience developing and presenting process/performance improvement projects.
• Experience presenting complex information to senior leadership teams.
• Experience leading multidisciplinary team projects.
• Experience identifying root cause and solution development including developing plans of correction.
• Strong interpersonal skills and communication abilities

• This is a remote role that can be done from most US states
• There are up to 8 onsite visits per year to the office in Assembly Row, Somerville

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender…