Compliance Consultant

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.

Key Responsibilities:

• 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

Key Qualifications:

• 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.)
• Knowledge of compliance and Quality improvement best practices
• Experience with auditing is preferred
  

Education and Experience:

• 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

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

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.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.