Quality Management Director - Healthcare jobs in West Virginia

Job Description

HEALTHCARE COMPLIANCE REVIEWER

This position is remote and not tied to any particular location.

HMS is seeking a Healthcare Compliance Reviewer focused on providing operational support and assistance with overall compliance and auditing activities. The Reviewer will complete predefined audit work to determine if insurance companies are conducting their operations in a manner that is compliant with rules, regulations, and governmental guidance. Compliance reviewers combine industry knowledge, business acumen and analytics to complete all assigned audit tasks and to provide specific and actionable recommendations.

Responsibilities:

• Develop and prioritize action plans to ensure timely completion of audits/reviews
• Perform research and analysis of regulatory updates and guidance issued by the Center for Consumer Information and Insurance Oversight (CCIIO) to Qualified Health Plan Issuers to ensure that testing is current and consistent with the National Association of Insurance Commissioners (NAIC) Market Regulation Handbook and federal regulations
• Perform research and analysis of data obtained for specific Qualified Health Plan Issuers
• Document the research and analysis that has been completed and provide supporting documentation for findings, specifically documenting how operational areas are not in compliance or where errors are identified
• Use audit software (TeamMate) by completing all required sections and all work within the appropriate work areas
• Prepare final reports and exhibits to summarize all findings
• Modify audit software to accurately reflect the report as issued after edits have been incorporated
• Identify findings requiring a Work Plan and monitor corrective actions
• Create and maintain deliverables and reports to support contractual and regulatory compliance
• Review and support the update of examination protocols when new regulations are released to ensure that they reflect the latest information
  
  

Desired Skills & Experience:

• An intermediate level of knowledge of Local, State, and Federal laws and regulations pertaining to the Affordable Care Act (ACA), health insurance, and/or healthcare services
• Knowledge of health care laws and regulations (HIPAA, ERISA) a plus
• Significant experience in the health insurance sector, specifically related to health care compliance, health care regulations, health care auditing, or fraud investigation
• 3 years internal/external auditing
• Strong understanding and commitment to professional auditing standards
• High level attention to detail
• Excellent decision-making abilities to determine appropriate course of action during reviews
• Ability to prepare detailed reports and to present findings clearly and accurately
• Proven ability to effectively perform Audits/Compliance Reviews in a discreet, confidential, and professional manner
• Good presentation skills to communicate with management and client(s)
• Willingness to travel approximately 20% of the time
• Ability to organize and prioritize tasks, and manage multiple priorities effectively
• Works independently; collaborates well with peers and clients
• Innovative; introduces new ideas and processes that improve performance and productivity
  
  

Minimum Education and Training Requirements:

• Bachelor's Degree plus 3 years of relevant experience or Master’s Degree and 1 years of relevant experience (Healthcare industry related is preferred). Equivalent combination of education and experience may be acceptable.
• Market Conduct Management (MCM) insurance designation
• TeamMate software experience desired
• Accredited Insurance Examiner (AIE) and Certified internal/external auditor (CIA) a plus
  
  

EOE STATEMENT

Healthcare Management Solutions, LLC has established an Affirmative Action Plan. HMS is deeply committed to the concept and practices associated with equal opportunity and affirmative action in all aspects of employment. HMS makes clear that all applicants will be treated without regard to race, color, sex, religion, national origin, age, disability, genetic information, sexual orientation, ancestry, marital status, changes in marital status, pregnancy or parenthood, gender, or gender identity or expression, military or veteran status, political affiliation, or any other protected characteristics under applicable law when the reasonable demands of the position(s) do not require distinction on the basis of age, disability, sex, marital status, changes in marital status, pregnancy, or parenthood.

This company does not tolerate unlawful discrimination in its employment practices. We recognize the value of diversity in our workforce, and encourage all qualified candidates to apply. We thank all candidates who choose to apply, however, only those selected for a further interview will be contacted.

Equal Opportunity Employer/M/F/Vet/Disabled

HMS is an EEO/AA/E-Verify compliant and drug free workplace employer.