Care Management Compliance Manager

Mass General Brigham • Somerville, MA

73d • $78,000 - $113,453

About The Position

The Care Management Operational Compliance Manager reports to the Director of Clinical Operational Compliance and collaborates closely with the Legal, Regulatory Affairs, and Compliance (LRAC) department. They will work directly with care management clinical teams to review, gather, and operationalize contractual and business requirements to provide guidance on high-risk, problem-prone areas in clinical program delivery and execution. This team member will provide clinical process expertise; identify impacts to programs & processes, workflows, systems, regulations, compliance, and performance standards while supporting the development of remediation activities and sustainable implementation of process improvement efforts to ensure operational excellence.

Requirements

• Bachelor's Degree required; Master's Degree preferred.
• Unrestricted RN license in state of residence.
• At least 3-5 years of clinical experience in a healthcare setting, with a focus on compliance and regulatory requirements.
• 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/InterQual criteria.
• 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.

Nice To Haves

• 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.
• Management or supervisory experience preferred.
• Knowledge of ICD-10-CM, CPT, and HCPCS codes.

Responsibilities

• Implement operational legal, regulatory and oversight within the care management teams.
• Monitor and evaluate 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.
• Lead the development of reports to drive risk mitigation and or improvement action plans.
• Communicate best practices, barriers, opportunities, and potential solutions to stakeholders.
• Support care management on process development and improvements related to regulatory changes and any remediation activities for CAPs.
• Act as a care management operations and compliance subject matter expert.
• Acquire and maintain detailed knowledge of federal and state compliance regulations.
• Facilitate communication between the designated teams and functional SMEs.
• Recommend additional key resources needed to meet project goals.
• Work in partnership with Learning & Development for proactive development and delivery of training.
• Identify knowledge gaps and areas of growth opportunities within the care management department.
• Participate in the development, review, and implementation of policies, procedures, and job aids.

Benefits

• Competitive base pay.
• Comprehensive benefits.
• Career advancement opportunities.
• Differentials, premiums and bonuses as applicable.
• Recognition programs designed to celebrate contributions and support professional growth.

What This Job Offers

• Job Type: Full-time
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees