Highmark Health Compliance Consultant in Pittsburgh, Pennsylvania
I. GENERAL OVERVIEW:
Program management of compliance-related projects conducted by assigned business owners (e.g., compliance analysts, senior compliance analysts, management, etc.) across all states and applicable departments for any type of regulatory requirement that is or may be applicable to the organization, as well as delegation oversight requirements across all applicable regulatory requirements. Maintains subject matter knowledge and expertise to educate and direct business owners on reviewer expectations to support compliance with current, new, and/or revised standards and guidelines. Demonstrates the ability to identify potential business impacts/compliance gaps across the organization and collaborates with and/or directs business owners on the development of solutions to mitigate risk. Reviews documentation developed by business owners to support compliance on an ongoing basis to ensure continuous audit preparedness. Represents the organization with external stakeholders (e.g., CMS, NCQA, BCBSA, state regulatory agencies, etc.) on regulatory requirement related matters. Project management of business owners within department for regulatory compliance-related tasks.
II. ESSENTIAL RESPONSIBILITIES:
Compliance: Review and interpret all new/revised requirements; identify potential impacts for the organization and/or business units; communicate information to applicable business owners/ management; complete gap analyses to identify actions required to support compliance; obtain input/direction from accrediting body/external consultant (as needed); and approve actions recommended by business units.
Program Management: Direct business owners and management across the organization on all aspects of regulatory requirements /delegation oversight. From a delegation oversight perspective: determination that delegation exists, agreement language, ongoing monitoring requirements, centralized reporting, and remediation options.
Project Management: Manage department-specific projects to support ongoing compliance with regulatory requirements by: developing and implementing work plans, obtaining status updates, reviewing outcomes, recommending changes (as needed), and working with the applicable business owner on finalization.
Consulting: Provide ongoing direction and support to business owners and management on compliance matters from a reviewer perspective, and coordinate queries to external stakeholders/consultant to resolve complex issues.
Auditing: Review all documents submitted to support compliance with requirements and provide feedback to business owners; coordinate and participate with the internal audit process; develop, implement, and monitor Plans of Correction (as needed); and communicate results to management.
Training: Develop training materials; identify scope of training (individuals and/or business units); schedule training sessions; and conduct training.
Contract Management: Maintain contracts with external bodies (as applicable); identify potential instances of material changes; obtain legal opinion; and report.
Governance: Chair/facilitate workgroups to ensure that compliance-related matters are reported as required, direction/input is received from applicable subject matter experts, and that adequate documentation is maintained of these discussions; develop/monitor reporting matrices; compile and present reports; and audit documentation.
Special Projects: As assigned by management.
Other duties as assigned or requested.
Bachelor’s Degree in Finance, Business, Public Policy, Public Administration, Communications, Pre-Law, or Accounting OR 6 years of relevant work experience
5-10 years of progressive experience in compliance, public policy, government affairs, project management, healthcare operations, law, auditing, or managed care
Working knowledge of applicable regulatory standards and guidelines and/or requirements (CMS and Medicaid regulations)
Experience interpreting regulations, assessing impacts, implementing processes to enhance compliance, and auditing results
Experience drafting/monitoring corrective action plans
Experience interacting with external regulatory representatives
Knowledge, Skills and Abilities
• Excellent verbal and written communication skills.
• Demonstrated ability to manage multiple and complex priorities.
• Demonstrated ability to work independently and take initiative.
• Demonstrated ability to meet compliance dealines.
V. WORK ENVIRONMENT
Is Travel Required?
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity