Director Medical Regulatory and Accreditation
Director Medical Regulatory and Accreditation
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Salary Not Disclosed
1 Vacancy
Job Description
Job Summary Director Medical Regulatory and Accreditation
Collaborates with the VP and senior leadership of Priority Healths Medical Management and legal/compliance departments in the development management implementation and oversight of strategies programs and activities to support operations for compliance with regulatory and accreditation requirements including Medicare Medicaid National Committee on Quality Assurance (NCQA) and other applicable federal and state regulations statutes and codes.
Coordinates activities with external partners such as health systems delegated entities and vendors in regard to regulatory and accreditation functions as those functions relate to Medical Management.
Supports activities and processes related to the medical policy life cycle.
Essential Functions Director Medical Regulatory and Accreditation
Responsible for the development management implementation and oversight of strategies programs and activities to support operational compliance with regulatory and accreditation requirements and to ensure Medicare Medicaid and NCQA audit readiness for the Medical Management department. This includes but is not limited to policies program descriptions audits/reviews for the department are appropriate up to date and operationalized.
Responsible for the annual risk assessments and mitigation strategies for Medical Management.
Responsible to know understand and monitor changes in applicable regulatory requirements and accreditation standards to evaluate impact for Medical Management strategies policies procedures programs and functional operations keeping the VP and senior leadership informed and providing support and guidance appropriately.
Responsible for the oversight of efficient and effective operations for the endtoend processes of medical policy review and implementation.
Maintain open lines of communication with Health Plan Compliance Officers and be responsive and accountable as a key contact for required communications actions deliverables required for compliance audits both internal and external on behalf of Medical Management.
Participate in Regulatory Oversight roles for Medical Management as assigned and be accountable for responsibilities as outlined in the Health Plans published regulatory organization and operations guidelines.
Responsible for monitoring activities to demonstrate compliance with federal and state regulatory requirements and applicable NCQA accreditation standards identifying issues timely and identifying and implementing education training process improvement and corrective action plans as necessary.
Mentors coaches and develops direct reports and acts as a role model and resource. Holds staff accountable for high performance against job descriptions policies & procedures controls and processes as well as organizational standards and policies. Completes performance reviews commends and initiates personnel actions such as interviewing hiring performance correction and terminations.
Qualifications Director Medical Regulatory and Accreditation
Required Bachelor Degree in health care or business related field
Preferred Master Degree
7 years of relevant experience in a health care related setting preferably managed care or health insurance Required
5 years of relevant experience direct management of staff Required
7 years of relevant experience Applying project management or auditing methods or managing and implementing projects processes audits or related role.
Solid understanding of Medicare regulations rules and guidelines or related State regulations Required#CHLI
Physical Demands Director Medical Regulatory and Accreditation
Pallet to Waist 6 from floor) > 5 lbs: Seldom up to 10 lbs
Waist to Waist > 5 lbs: Seldom up to 10 lbs
Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
Waist to Overhead > 5 lbs: Seldom up to 10 lbs
Bilateral Carry > 5 lbs: Seldom up to 10 lbs
Unilateral Carry > 5 lbs: Seldom up to 10 lbs
Pushing Force > 5 lbs: Seldom up to 10 lbs
Pulling Force > 5 lbs: Seldom up to 10 lbs
Sitting: Frequently
Standing: Occasionally
Walking: Occasionally
Forward Bend Standing: Seldom
Forward Bend Sitting: Occasionally
Trunk Rotation Standing: Seldom
Trunk Rotation Sitting: Occasionally
Reach Above Shoulder: Seldom
Reach at Shoulder or Below: Seldom
Handling: Occasionally
Forceful Grip > 5 lbs: Seldom
Forceful Pinch > 2 lbs: Seldom
Finger/Hand Dexterity: Frequently
How Corewell Health cares for you
Comprehensive benefits package to meet your financial health and work/life balance goals. Learn more here.
Ondemand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you like restaurants phone plans spas and more!
Optional identity theft protection home and auto insurance pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status
Primary Location
SITE Priority Health 1231 E Beltline Grand RapidsDepartment Name
PH Medical ManagementEmployment Type
Full timeShift
Day (United States of America)Weekly Scheduled Hours
40Hours of Work
8:00 a.m. to 5:00 p.m.Days Worked
Monday to FridayWeekend Frequency
N/ACURRENT COREWELL HEALTH TEAM MEMBERS Please apply through Find Jobs from your Workday team member account. This career site is for NonCorewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members patients visitors and community. We require a drugfree workplace and require team members to comply with the MMR Varicella Tdap and Influenza vaccine requirement if in an onsite or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process to perform the essential functions of a job or to enjoy equal benefits and privileges of employment due to a disability pregnancy or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race color national origin sex disability age religion genetic information marital status height weight gender pregnancy sexual orientation gender identity or expression veteran status or any other legally protected category.
An interconnected collaborative culture where all are encouraged to bring their whole selves to work is vital to the health of our organization. As a health system we advocate for equity as we care for our patients our communities and each other. From workshops that develop cultural intelligence to our inclusion resource groups for people to find community and empowerment at work we are dedicated to ongoing resources that advance our values of diversity equity and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
Required Experience:
Director
Employment Type
Full-Time
