Compliance Consultant

Blue Cross Blue Shield of Massachusetts-posted 6 days ago
Full-time • Mid Level
Hingham, MA
1,001-5,000 employees
Resume
Match Score
Upload and Match ResumeTrack Jobs with Teal

Ready to help us transform healthcare? Bring your true colors to blue. The Role: The Compliance Program Consultant will focus on utilization management compliance and audit readiness activities such as evaluating and supporting Health and Medical Management’s (HMM) and delegate’s compliance with the applicable NCQA utilization management standards and state and federal regulations. The Team: This consultant will support cross-functional projects. These projects may include delegation, mock audits, risk assessments, and preparing documentation for regulatory or accreditation submission. The role involves working under the direction of project leaders and collaborating with other departments, external delegates, and team members to support corporate initiatives. This role is eligible for the Flex persona.

  • Under the direction of supervisor, analyze and investigate results of monitoring/audits, identify trends, and draft recommendations to systems and procedures that will mitigate risk to the organization.
  • Assist with internal clinical compliance initiatives, working closely with applicable teams/leaders, to assure action plans are completed and risk is mitigated in a timely manner.
  • Support the implementation of Clinical Compliance Policies and Procedures.
  • Assist with conducting audits.
  • Act as a resource for NCQA and state and federal regulations such as applicable Massachusetts and Rhode Island regulations
  • Meeting planning & facilitation
  • Works with team on process improvements
  • Participate in cross functional meetings; keep project leaders and supervisor informed of key issues, risks, timetables, and project milestones
  • Other responsibilities as identified by the Director
  • Strong attention to detail, Problem-solving and critical thinking skills
  • Strong organization and time management skills including the ability to meet deadlines and manage multiple competing priorities
  • Meeting facilitation skills
  • Excellent interpersonal, verbal and written communications skills
  • Familiarity with NCQA, CMS, FEP and other State and Federal regulatory and accrediting requirement/ standards
  • Knowledge of utilization management systems, functions, and processes/ workflows
  • Knowledge of NCQA UM accreditation requirements, Massachusetts, and Rhode Island utilization review regulations
  • Proficiency in Microsoft Office (Word, Excel, PowerPoint, etc.)
  • RN or clinical professional degree with active Massachusetts clinical license with 3 years of clinical experience
  • Bachelor’s degree in clinical discipline required, 2 years of utilization management experience required; health insurance experience preferred
  • 1-2 years of experience working with or familiarity with utilization management regulatory and accreditation standards, such as NCQA, Massachusetts utilization review regulations, Rhode Island utilization review regulations, Federal Employee Plan
  • High school degree or equivalent required unless otherwise noted above
  • Knowledge of compliance and Quality improvement best practices
  • Experience with auditing is preferred
  • We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
Track Jobs with Teal

Job Search Resources

•
Resume Builder
•
Compliance Officer Resume Examples
•
Compliance Officer Cover Letter Examples

Tools

Career Hubs

Guides

Company

© 2024 Teal Labs, Inc
Privacy PolicyTerms of Service