Executive Services Compliance Specialist

<p>With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.</p>

Detroit, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="https://www.bcbsm.com/" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="http://www.bcbsm.com/index/about-us/our-company.html" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />Learn more about your options as an external candidate. <a href="https://bcbsm.taleo.net/careersection/2/jobsearch.ftl?lang=en" target="_blank" rel="noopener noreferrer">Click here</a> to view open positions.&nbsp; http://www.bcbsm.com

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Competitive Total Compensation Package

Overview: Interacts with Public Policy, the Office of National Health Care Reform, Regulatory Affairs, and the NCQA Accreditation Team for the purpose of integrating regulatory and other changes in the Executive Services&rsquo; policies, processes and procedures for the purpose of achieving and remaining compliant with federal and state regulations and NCQA.&nbsp;&nbsp;The position will also provide and/or arrange for training of new/updates rules and regulations and will maintain the Executive Services Quality program and related audits and remediate results.
Responsibilities: <ul> <li>Oversees department&rsquo;s Quality Program &amp; Perform Quality Audits.&nbsp;&nbsp;Remediate quality concerns through updated processes, documentation and feedback to Team Leaders, corrections to letter templates etc.; lead and implement related process improvements; develop/review/monitor statistical reporting on Quality</li> <li>Accounts for the National Committee Quality Assurance (NCQA) Compliance:</li> </ul> <ul> <li>a.&nbsp;Update all policies and procedures annually and secures approval through the appropriate NCQA committee (State and Federal Appeals Policies ,&nbsp;&nbsp;&nbsp;Appeals resulting from Complaints Policy, Administrative and Clinical Complaints Policies, Intake Complaint procedures).</li> <li>b.&nbsp;&nbsp;Obtains monthly statistical reports from the Executive Services Appeals&nbsp;&nbsp;database; works with Technician Team Lead to remediate any inaccurate or missing data.</li> <li>c.&nbsp; &nbsp;Statistical Reporting and Analysis to meet NCQA Accreditation Requirements:&nbsp;&nbsp;Sort, review and analyze data and related complaint and appeal cases to produce monthly reports to obtain/maintain NCQA Accreditation (Annual Complaints and Appeals Report and Quarterly Complaints and Appeals Reports).</li> <li>d.&nbsp;&nbsp;&nbsp;Coordinates Reporting of Clinical Complaints</li> <ul> <li>&nbsp; &nbsp;&nbsp;i.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Obtain Clinical Complaint Data from Blue Care Network (BCN); analyze and integrate into NCQA reports.</li> <li>&nbsp; &nbsp;&nbsp;ii.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Work with BCN to enhance reporting data and produce additional NCQA Reports as needed (Quarterly Clinical Complaint Reporting to meet CR 6 and CR 9 standards and presentation of Clinical Complaint Data to the Corporate Quality Improvement Committee quarterly).</li> </ul> <li>e.&nbsp;&nbsp;&nbsp;Creates NCQA presentations and presents at the associated Corporate Committee meeting (Utilization Management Committee, Member Experience Committee, and Quality Improvement Committee).</li> <li>f.&nbsp;&nbsp;&nbsp;&nbsp;Submits and tags all documentation and reports to the NCQA SharePoint Site to meet accreditation standards.</li> <li>g.&nbsp;&nbsp;&nbsp;&nbsp;Represents Executive Services at all accreditation related meetings and work groups.&nbsp;&nbsp;</li> <li>Participates in monthly meetings with the HIPAA Compliance Office and implement/update processes for full compliance. Monitor the Confidential Communication Process to ensure that safeguards for CCs work as intended.</li> <li>Coordinates appeals data and works with Regulatory Affairs to coordinate the submission of the annual appeals report to the Department of Insurance and Financial Services (DIFS). Works directly with DIFS to validate the annual complaint report.</li> <li>Reviews and maintains Department Service Level Agreements.</li> <li>Coordinates transition to mutualization by processing and documenting changes related to provider appeals process and changes to PA 250.</li> <li>&nbsp;Coordinates &ldquo;Voice of the Customer&rdquo; by monthly analysis and reporting of complaints and appeals trends and verbatim to the Voice of the Customer group; attend Voice of the Customer workgroup meetings.</li> <li>Implements and maintains Member Complaint Process:&nbsp;&nbsp;Refine and remediate the complaint process; clarify interfaces with other corporate areas; update process documentation as needed; coordinate Customer Service interface; coordinate documentation updates (CSI&rsquo;s to customer services and MiSource updates of related policies and procedures); continue improvements of the BCN interface for processing and reporting on complaints</li> <li>Leads projects and supports manager:&nbsp;&nbsp;Projects may be related to NCQA accreditation, corporate/departmental process improvement, documentation creation and review, national healthcare reform, letter template enhancements, workgroups, represent Executive Services at corporate workgroup meetings, work with Manager of Executive Services to develop yearly strategic plan and goals, monitor and report on yearly plans and attainment of goals (scorecard)</li> </ul>
Requirements: <ul style="font-weight: 400;"> <li>Bachelor's Degree in business administration or a related field required.</li> <li>Five (5) years of compliance experience required preferably in the health insurance industry.</li> <li>Two (2) years of leadership experience preferred.</li> <li>Knowledge of NCQA Accreditation process and standards preferred.</li> <li>Demonstrated knowledge and competency in process improvement, project management, strategic planning.</li> <li>Excellent written/verbal communication skills.</li> <li>Proven ability to speak effectively before groups and facilitate workgroups and meetings.</li> <li>Excellent analytical, organizational, problem-solving, and critical thinking skills.</li> <li>Proficiency in PC applications such as Excel, PowerPoint, and Access.</li> <li>Ability to manage multiple projects and initiatives, prioritize workloads and meet deadlines, and perform under pressure and within tight time constraints.</li> </ul> <p style="font-weight: 400;"><em>All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.</em></p>