Care Management Compliance Manager

Care Management Operational Compliance Manager

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 SME's.
• 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.

Qualifications :

Knowledge and Skills :

Abilities / Competencies :

Additional Job Details (if applicable) :

Working Conditions :

Pay Range : $78,000.00 - $113,453.60 / 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 package. In 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.

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.