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Director, Medical Management Compliance

Company: Capital BlueCross
Location: Harrisburg
Posted on: February 24, 2021

Job Description:

The Director of Compliance for Medical Management is responsible for the operations of the compliance and audit activities within Medical Management. Medical Management includes utilization management and care management programs.
This position has direct responsibility for compliance, vendor oversight, and the notification operation team.

The Director of Compliance for Medical Management is responsible for administering programs in accordance with National Committee for Quality Assurance (NCQA), CMS and State and Federal regulatory agency requirements. This includes supporting audit and accreditation activities.

The Director of Compliance for Medical Management is responsible for ensuring vendor activities and service level agreements comply with the contract and monitoring vendor compliance activities.Job Requirements:Leadership:

  • Proven work experience at the management level. Leading teams of staff with varying functions.
  • In-depth knowledge of performance metrics
  • Excellent communication and leadership skills
  • Organizational and time-management skills
  • Decision-making skills
  • Change management experience
  • Team development experienceKnowledge:
    • Knowledge of current and emerging clinical management practices.
    • Knowledge of current and emerging clinical practices.
    • Knowledge of Medicare coverage criteria and online tools available to remain current.
    • Knowledge of NCQA, CMS and state and federal requirements. .
    • Knowledge of HEDIS requirements.
    • Knowledge of workload planning and staff management concepts.
    • Knowledge of productivity monitoring and tools.
    • Knowledge of Implementation process and management.
    • Knowledge of medical management systemSkills:
      • Good PC skills, Computer literate with the ability to process requests on-line
      • Excellent communication skills; written and verbal. Demonstrated public speaking skills
      • Microsoft applications; outlook, word, excel, visio, project proficient.
      • Problem solving and critical thinking skills with solid decision-making skills--
      • Team player; ability to work cross-functionally
      • Mentor/coaching skillsExperience:
        • A minimum of ten years of successful management experience in a health care related business.
        • A minimum of five years experience in medical management activities, including utilization review . Education, Certification, and Licenses:
          • Minimum requirements include a Bachelor's Degree in a health related field, as well as licensure as a health professional. A Master's Degree is preferred.Work Environment: Ability to work remotely/virtualTravel Requirements: --As neededPhysical Demands: While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds.Key Interfaces: --Capital employees and vendorsNumber of direct and indirect reports: 15Budget Responsibilities: --Yes Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.-- Posted 2 Days Ago Full time R2096 About Us Capital BlueCross has built a reputation as being "more than" a health insurance company. We are an industry and community leader that understands the foundation of our success is serving people-addressing their needs, guiding them through their health and wellness journey, exceeding their expectations, and giving back to the communities we serve. We could not accomplish these goals without our employees, which is why we work so hard to provide a positive, supporting culture that encourages and rewards excellence. Capital BlueCross offers competitive pay, bonus opportunities, quality benefits, health and wellness incentives, and opportunities for career advancement and community involvement. Our positive workplace culture and employee involvement in our communities have earned us recognition as one of The Best Places to Work in PA and Corporate Citizen of the Year. The success of our company relates directly to the efforts of our dedicated workforce made up of talented individuals, who understand that a career at Capital BlueCross is "more than" simply a job. To experience that kind of opportunity, consider applying to join our fearless team.

Keywords: Capital BlueCross, Harrisburg , Director, Medical Management Compliance, Executive , Harrisburg, Pennsylvania

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