Job Description

Manage, oversee, monitor, and conduct internal and external auditing and real-time monitoring activities related to the Health Plan's regulatory and contractual requirements in accordance with the Compliance Program, as well as associated compliance oversight and reporting to align with regulatory and contractual requirements in accordance with the Compliance Program, and with HHSC, TDI, NCQA and Health Plan Senior Management.

• Ensure ongoing compliance with federal and state regulations and provide guidance and tools to assist the Health Plan in developing an auditing and monitoring program. Develop comprehensive audit tools to objectively measure internal performance and performance of third parties (i.e. subcontractors) against Health Plan metrics, policies, regulations, and industry standards. Internal and external audit tools with measurable metrics will be created with feedback from Senior Management and must be reviewed and/or revised at least once annually.

• Knowledge of general business systems and their related control structures, extensive knowledge healthcare regulatory environment, including CMS, HIPAA, and HITECH regulations.
• Must have technical knowledge related to personal computers and business information systems and related applications.

• Ability to analyze data and situations, determine errors and potential problems arising from the analyses, and formulate practical and workable solutions to the problems identified.
• Must be able to utilize computer word processing, spreadsheet and graphics software applications.
• Must be able to work effectively with all levels of management and be able to write clearly and effectively.

Would prefer if they had Tapestry experience
Mandatory provider contract, benefit, fee schedule configuration experience
Business Operations and Leadership
Epic Certifications and Experience Claims, Contracts, Benefits (preferred)
Demonstrated configuration experience in contracts, benefits or fee schedules
Demonstrated experience in applying regulatory medical coding guidelines to development of guidelines and configuration of the system for provider contracts, benefits and fee schedules
Claims adjudication experience (preferred)
Skilled in using technology to provide/ improve solutions
Demonstrated experience in effective management of resources & inventory management
Demonstrated experience in reporting, business strategy
Demonstrated implementation / management of quality programs 

Required- Bachelor's Degree

Preferred- CCEP - Cert Compliance & Ethics Prof Healthcare Compliance Association Or
CHC - Certified in Healthcare Compliance American Institute of Healthcare Compliance Or
CHC - Certified in Healthcare Compliance Compliance Certification Board (CCB)

Required- 5 years progressive compliance, auditing, healthcare, and/or legal experience

Job Tags

Contract work, For subcontractor,

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