Care Management Compliance Manager

Site: Mass General Brigham Health Plan Holding Company Inc.

Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

The Care Management Operational Compliance Manager reports to the Director of Clinical Operational Compliance and collaborates closely with the Legal Regulatory Affairs and Compliance (LRAC) department. They will work directly with care management clinical teams to review gather and operationalize contractual and business requirements to provide guidance on high-risk problem-prone areas in clinical program delivery and execution. This team member will provide clinical process expertise; identify impacts to programs & processes workflows systems regulations compliance and performance standards while supporting the development of remediation activities and sustainable implementation of process improvement efforts to ensure operational excellence.

Principal Duties and Responsibilities:

Implement operational legal regulatory and oversight within the care management teams.
Monitoring and Evaluation of end-to-end care management activities
Facilitate the implementation of routine monitoring tools/ for ongoing monitoring of clinical adherence to CMS and State-specific requirements.
Conduct standard qualitative and quantitative chart reviews in accordance with established procedures for monitoring of adherence to contractual requirements.
Perform and/or collaborate with LRAC and other business teams to conduct readiness audits.
Identify gaps and work with business owners to prioritize and address.

Evaluate care management operational compliance activities to drive performance improvement.
Evaluation of end-to-end care management activities related to compliance.
Timeliness of contractually required services.
Service plan/ plan of care execution and documentation to state requirements.
Lead the development of reports to drive risk mitigation and or improvement action plans.
Communicate best practices barriers opportunities and potential solutions to stakeholders.
Supports care management on process development and improvements related to regulatory changes and any remediation activities for CAPs etc.

Act as a care management operations and compliance subject matter expert.
Acquire and maintain detailed knowledge of federal and state compliance regulations (e.g. mental health parity).
Maintain knowledge of other industry requirements (e.g. NCQA) and communicate connections to business leaders between industry bodies and regulators.
Function as Subject Matter Expert of clinical contractual requirements.
Facilitate communication between the designated teams and functional SMEs.
Consult with Regulatory Adherence/HP compliance to meet applicable rules and regulations.
Recommend additional key resources needed to meet project goals.

Facilitate care management clinical operational compliance-related training.
Works in partnership with Learning & Development for proactive development and delivery of training on opportunities identified from oversight activities.
Identify knowledge gaps and areas of growth opportunities within the care management department.
Partner with clinical training resource(s) to ensure training meets regulatory and contractual standards and aligns with operational policies and procedures.

Policy Procedure Job Aid oversight and development support
Participate in the development review and implementation of policies procedures and job aids to ensure operational compliance across documents and operations.
Collaborate with LRAC on the annual review process for care management documents.

Education

• Bachelors Degree required; Masters Degree preferred

Licenses and Credentials

• Unrestricted RN license in state of residence

Experience

Required

• At least 3-5 years of clinical experience in a healthcare setting with a focus on compliance and regulatory requirements required

Preferred

• At least 5 years of clinical nursing experience strongly preferred
• At least 2 years of Medicare Medicaid and DSNP Managed Care Experience strongly preferred
• At least 2 years of experience with contract interpretation/compliance strongly preferred
• Masters degree and or managed care experience at the management level preferred
• Knowledge of NCQA standards and CMS & DMHC regulations
• Knowledge of Quality Improvement philosophy and techniques
• Knowledge of Medicare Local Coverage Determination National Coverage Determination and MCG/InterQual criteria
• Understanding of Project Management
• Management or supervisory experience preferred.
• Knowledge of ICD-10-CM CPT and HCPCS codes

Knowledge and Skills

• In-depth knowledge of healthcare laws regulations and standards related to clinical practices.
• Strong analytical and problem-solving skills.
• Excellent communication and interpersonal skills.
• Proven experience in developing and implementing clinical compliance programs.
• Detail-oriented with the ability to interpret and apply complex regulatory requirements.

Abilities/Competencies

• Proficiency in all Microsoft Office Programs
• Experience in data analysis.
• Proven ability to identify operational process gaps and clinical gaps in care.
• Experience developing and presenting process/performance improvement projects.
• Experience presenting complex information to senior leadership teams.
• Experience leading multidisciplinary team projects.
• Experience identifying root cause and solution development including developing plans of correction.
• Strong interpersonal skills and communication abilities

Working Conditions

• This is a remote role that can be done from most US states
• There are up to 8 onsite visits per year to the office in Assembly Row Somerville

Remote

399 Revolution Drive

40

Regular

Day (United States of America)

Pay Range

$78000.00 - $113453.60/Annual

Grade

7

At Mass General Brigham we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive and any offer extended will take into account your skills relevant experience if applicable education certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however it does not encompass all elements contributing to your total compensation addition to competitive base pay we offer comprehensive benefits career advancement opportunities differentials premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

Mass General Brigham Health Plan Holding Company Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religious creed national origin sex age gender identity disability sexual orientation military service genetic information and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process to perform essential job functions and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973 the Vietnam Veterans Readjustment Act of 1974 and Title I of the Americans with Disabilities Act of 1990 applicants who require accommodation in the job application process may contact Human Resources at .

Mass General Brigham Competency Framework