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Why This Role is Important to Us:
Position Summary:
The Director, Quality & Control Assurance reports to the VP of Quality & Control Assurance is responsible for providing strategic leadership and oversight for the Quality & Control Assurance within CCA’s Compliance department. This position designs, continually matures, promotes, & develops a program that adheres to all applicable federal, state, and contractual requirements.
This position and is responsible for designing quality and control assurance reviews of claims, Hierarchical Condition Categories (HCC) and clinical coding, call monitoring, system technology upgrades, and other critical compliance/financial/operational controls and processes across the CCA enterprise, including all health plan and care delivery activities. These responsibilities include planning, executing, and evaluating results of quality audits/reviews and control/operational integrity initiatives, evaluating error patterns and trends, and ensuring the reporting of relevant quality audit/review results, call monitoring reviews, and evaluation of HCC audits/reviews, among others, to relevant departments.
The role also leads the department’s focused review and internal controls assurance; SOX/SOC/MAR (Model Audit Rule) testing/assurance; technology/systems assurance; external and regulatory audit management, support, and facilitation; and CAP remediation teams. The role and department evaluate statistical patterns and trends of quality and controls assurance results and collaborate with owners of audited/reviewed business areas to address root causation of errors and facilitate overall quality improvement.
Supervision Exercised:
What You'll Be Doing:
Essential Duties & Responsibilities:
Under the guidance of the VP, Quality & Control Assurance assist with providing strategic leadership and oversight for the Quality & Control Assurance within CCA’s Compliance department.
Designs, builds, develops, assesses, and adapts clear and effective Quality Assurance and controls monitoring, audits/reviews, testing, reporting, and audit sampling methodologies to ensure proper, effective, and timely assessments. Conducts regular assessments of existing quality audit protocols, activities, and reports; develops new protocols as necessary; and facilitates effective remediation of findings and corrective actions. Updates and ensures protocols and controls are followed, including timely completion of quality audits/reviews and controls assurance assessments.
Develop, maintain, revise, and ensure accuracy of Quality & Control Assurance policies & procedures, SOPs, risk assessments, and work plans.
Provides clear and effective reports to the relevant business, functional and operational areas, as well as other internal/external stakeholders, regarding quality audit/review findings, contractual requirements, industry standards and best practices.
Conducts regular and ongoing risk-based evaluation of new quality audit/review opportunities and conducts regular evaluation of the methodology and relevance of existing audits. Oversees and directs regular gap analyses, risk assessments and program effectiveness assessments for the different Quality & Controls Assurance programs and functions.
Establishes and ensures quality standards by designing effective quality audits/reviews and controls assessments and selecting the most appropriate and effective sampling methodology to test quality on audited samples.
Ensure maximum productivity on all quality audits/reviews and controls assessments, which provide management and leadership with timely, effective, and valuable feedback. Analyze, evaluate, and present information concerning relevant factors, such as business scenarios, production capabilities, and design and development of department workflows. Maintain databases, dashboards, scorecards, and reports of production, statistical, operational, and financial results.
Responsible for Quality & Controls Assurance programs, activities and reviews, including claims reviews; call center and digital communications reviews; Medicare Risk Adjustment, HCC, clinical and coding reviews; DRG and medical records reviews; technology/systems and coding upgrade and implementation reviews (e.g. final user acceptance testing, etc.); Government Programs product compliance reviews; operational reviews (e.g. enrollment and eligibility, ID cards, premium billing, EOBs, coordination of benefits, etc.); select vendor reviews; product-specific samples and reviews; focused review and internal controls testing and assurance; SOX/SOC/MAR testing and assurance; external and regulatory audit management, support, facilitation and reporting; CAP remediation oversight, support, facilitation and reporting; and GRC tool/solution, technology and data analytics implementation and utilization, among other department activities.
Represent the Quality & Controls Assurance Department to internal and external customers and stakeholders, including regulatory agencies, to build and maintain positive relationships that support business goals and objectives.
Perform other duties as assigned. Effectively live, role model, communicate, and support the values of CCA. Effectively build trust, rapport, credibility, partnerships, working relationships, consensus, and coalitions with all business, operational, functional, internal, and external constituents, and at all levels of the organization. Perform in accordance with CCA competencies and behaviors.
Working Conditions:
What We're Looking For:
Required Education:
Desired Education/Licensing:
Required Experience:
8+ years of audit (internal and/or external), quality assurance/review, internal controls and assurance, risk management, corporate governance, compliance and/or related experience required, with heavy preference for highly substantive audit, assurance, and internal controls experience.
3+ years of experience in healthcare industry with strong preference for health plan, managed care, government programs and payer organization focus.
3+ years of managerial and people leadership experience.
Demonstrated experience in managing a substantial portfolio of audits, quality assurance reviews, internal controls reviews, remediation initiatives, concurrent oversight, and execution of multiple projects, and evaluating controls associated with complex business processes.
Desired Experience:
Required Knowledge, Skills & Abilities:
Strong knowledge of and/or experience with government programs regulatory, operational, financial, and clinical requirements for the delivery of health insurance and managed care products and services, including Medicare, Medicaid, MMP, LTSS, SNP, Duals, CHIP, and behavioral health, as well as the associated and relevant federal, state, and local regulatory entities.
Strong knowledge of government programs, health insurance, managed care, and payer/provider information systems, functions, and continuous monitoring software to be used as tools for effectively meeting QA and internal controls assurance objectives.
Excellent partnership-, working relationship-, consensus- and coalition-building skills to foster and maintain highly effective relationships throughout the organization.
Excellent communication and influencing skills, both direct and indirect.
Strong consultative and partnership approach that strikes the optimal balance between meeting regulatory and risk management requirements, and understanding and supporting the broader macro industry, strategic, business, and operational needs.
Strong emotional intelligence required. Open, communicative, transparent, collaborative, and action-oriented leader who builds high-performing teams and department cultures and who continuously fosters strong relationships and partnerships across the enterprise.
Strong integrity capital with commitment to doing the right thing and living/upholding organizational values.
Required Language:
EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.