Health Services Regulatory Manager

Company: Careerbuilder-US
Location: Boise
Posted on: November 25, 2022

Job Description:

Looking for a way to make an impact and help people?Join PacificSource and help our members access quality, affordable care!PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.Position Overview: Oversees all aspects of the Health Services (HS) regulatory requirements for Utilization Management (UM), Care Management (CM), and Appeals and Grievances (AG). Ensures operations are processed according to State, NCQA, Medicare and Medicaid regulations. The HS Regulatory Manager is responsible for working with other department leaders to continuously improve internal operations, secure a high quality and compliant output of operations, and successfully execute favorable internal and external audit outcomes.Essential Responsibilities:Develop and implement the annual HS regulatory work plan.Identify and take necessary steps to implement opportunities improving the quality of and adherence to regulatory required processes.Ensure evaluation, review and implementation of member and plan documents meet HS regulatory standards.Ensure timely response to customers, for adherence to contractual and regulatory requirements.Present monthly, quarterly, bi-annual and annual reports to the Clinical Quality Utilization Management (CQUM) Committee, Quality Improvement Committee and other internal and external agencies as mandated by Federal/State requirements.Ensure applicable regulatory reports for State, CMS, OHA, and NCQA are completed and submitted accurately and timely.Build and deploy a successful Quality Assurance monitoring and audit process to ensure adherence to regulatory requirements for UM, CM and AG, and delegated functions therein those areas.Perform job responsibilities in accordance with all applicable state and federal regulations and within the scope of the Company Compliance Program.Provide routine risk assessments and elevate opportunities found from monitoring and audit outcomes to leadership and/or applicable forums.Work collaboratively with departments to timely resolve issues of non-compliance.Provide recommendations of training opportunities to company staff regarding updated and new regulatory requirements.Work collaboratively with PS Corporate Compliance department and NCQA program representatives regarding CMS, OHA, NCQA and State agencies on regulatory issues impacting UM, CM, and AG.Partner with PS Corporate Compliance department and NCQA Program representatives to plan and execute deliverables for Data submissions, Reports and External audits.Oversee daily operations of HS Regulatory staff and cultivate an engaged and subject expert workforce.Responsible for oversight, management, development, implementation, and communication of department regulatory requirements.Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.Develop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.Coordinate business activities by maintaining collaborative partnerships with key departments.Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.Actively participate as a key team member in Manager/Supervisor meetings.Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.Supporting Responsibilities :Meet department and company performance and attendance expectations.Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.Perform other duties as assigned.SUCCESS PROFILEWork Experience: A minimum of five years in healthcare/insurance industry, state/federal regulations and/or audit experience required. Demonstrated knowledge and experience managing/supervising personnel, program development, planning and deployment.Education, Certificates, Licenses: A bachelor's degree in related field or equivalent professional level experience.Knowledge: Basic Computer Skills in a Windows Operating System Environment as well as intermediate proficiency in Microsoft Office Applications. Thorough knowledge of Medicare and Medicaid programs, Grievance/Appeals federal and state regulations. Knowledge of claims and authorization process/methodology, medical terminology and coding, HIPAA laws/regulations and labor laws as pertains to hiring/firing employees.CompetenciesBuilding TrustBuilding a Successful TeamAligning Performance for SuccessBuilding PartnershipsCustomer FocusContinuous ImprovementDecision MakingFacilitating ChangeLeveraging DiversityDriving for ResultsEnvironment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.Our ValuesWe live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:We are committed to doing the right thing.We are one team working toward a common goal.We are each responsible for customer service.We practice open communication at all levels of the company to foster individual, team and company growth.We actively participate in efforts to improve our many communities-internally and externally.We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.We encourage creativity, innovation, and the pursuit of excellence.Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.This employer is a corporate member ofmyGwork - LGBTQ+ professionals, the business community for LGBTQ+ professionals,students, inclusive employers & anyone who believes in workplace equality.

Keywords: Careerbuilder-US, Boise , Health Services Regulatory Manager, Healthcare , Boise, Idaho