Provider Relations Regulatory Compliance Manager, Fairfield, CA
Provider Relations Regulatory Compliance Manager
Responsible for supporting the Provider Relations Department’s (PR) role in the Plan’s initiative to achieve and maintain NCQA accreditation. Develops materials and documentation and is responsible for ongoing oversight to ensure department operations meet PR’s NCQA designated standards. Position requires excellent working knowledge of provider data to manage data integrity and handle provider network regulatory functions, including preparation of written responses and reports to Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC).
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Serve as the department’s subject matter expert and resource for NCQA Credentialing and Network Standards. Manage PR NCQA project plan, complete assignments, notify dept. of upcoming deliverables and escalate concerns as necessary to mitigate risks.
- Identify gaps in policies and procedures, workflows, evidence based documentation and reporting tools. Recommend solutions and develop documentation to meet standards.
- Oversee implementation and integration into daily operations of NCQA standards owned by PR, including documents, procedures, reports, process flows and tools.
- Draft policies and procedures and establish effective systems for organized housing of documentation that demonstrates compliance with standards.
- Collaborate with functional areas to complete NCQA activities timely and accurately.
- Educate and train department staff regarding applicable accreditation standards and their respective responsibilities in carrying out functions required to meet standards.
- Monitor PR’s NCQA operational compliance quarterly, including evaluating delegates’ compliance with Credentialing and Network standards, providing management with status reports and vulnerabilities with recommendations of actions to correct deficiencies. Monitor corrective action plans related to NCQA.
- Serve as department liaison between PR and IT for data reporting and validation.
- Serve as department liaison between PR and Compliance and Regulatory Affairs departments, ensuring timely response to DHCS and DMHC inquiries.
- Research, analyze and write comprehensive responses to regulators for data inquiries regarding access to care, accuracy and analysis of provider network data.
- Support requests for internal provider reporting.
- In conjunction with IT, develop written specifications for all PR reporting and establish a process for ongoing updates.
- Ensure and oversee audit criteria and processes are in place for monthly review of accuracy of provider data in collaboration with IT and the data warehouse teams.
- Develop, implement and audit standards for database integrity and quality assurance to ensure PR data is accurately reporting according the DHCS and DMHC requirements.
- Attend DHCS/DMHC webinars and meetings involving provider network data.
- Ensure DHCS All Plan Letters affecting PR operations are implemented.
- Participate on cross-departmental provider data and regulatory workgroups, including system consolidation and core system evaluations.
MINIMUM HIRING CRITERIA
Education and Experience Bachelor’s degree in related field preferred; minimum two (2) years of experience in program/project management and working with NCQA accreditation requirements preferred; Experience analyzing and drafting responses to DHCS regulatory inquiries regarding data and/or implementation of new regulations preferred. Knowledge of Medi- Cal/DHCS and DMHC/Knox-Keene regulations.
Special Skills, Licenses and Certifications Extensive knowledge of NCQA standards. Proven success driving and supporting cross-functional projects in a health care environment.
Working knowledge of business software applications. Knowledge of managed care concepts, policies and procedures. Valid California driver’s license is required. Must have access to own reliable vehicle.
Performance Based Competencies Excellent oral and written communication skills. Strong planning, organizational and problem solving skills with the ability to prioritize assignments, maintain accurate records, and meet deadlines. Ability to use good judgment in making decisions within scope of authority and to handle sensitive issues with tact and diplomacy.
Work Environment And Physical Demands Ability to use a computer keyboard. More than 50% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 25 pounds.
All HealthPlan employees are expected to:
- Provide the highest possible level of service to clients;
- Promote teamwork and cooperative effort among employees;
- Maintain safe practices; and
- Abide by the Health Plan’s policies and procedures, as they may from time to time be updated.
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
Fairfield, California, United States
Additional Preferred Skills