Manager Risk and Quality Assurance

Company

Highmark Health

Job Description

JOB SUMMARY

This job has oversight responsibility for all risk & quality assurance studies required by regulators, the Blue Cross Blue Shield Association (BCBSA), accreditation bodies, executive management, plan partners, group customers, and employee level performance. The programs for which the department is currently wholly or partially responsible for are (a) the BCBSA's Member Touchpoint Measures (MTM), Licensee Desk Level Audit (LDLA), and Federal Employee Program (FEP) Quality Program, (b) the National Committee for Quality Assurance (NCQA), (c) Joint Commission accreditation compliance, (d) quality measures required by state regulators, (e) certain quality measures related to group and partner plan contractual performance guarantees / service level agreements, and (f) employee performance quality.

ESSENTIAL RESPONSIBILITIES

• Perform management responsibilities to include, but are not limited to involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
• Manages global team responsible for accreditation and quality assurance across the enterprise. Responsible for managing and controlling (a) the BCBSA's Member Touchpoint Measures (MTM), Licensee Desk Level Audit (LDLA), and Federal Employee Program Quality Program, (b) the National Committee for Quality Assurance (NCQA) compliance, (c) Joint Commission accreditation compliance, (d) quality measures required by state regulators, (e) certain quality measures related to group and partner plan contractual performance guarantees / service level agreements, and (f) employee performance quality.
• Manages global team responsible for assessing and guiding business owners on activities required to ensure ongoing quality and accreditation program compliance; revises departmental work plans based on results (as needed); and conducts quality checks of all documents prior to formal submission to applicable accrediting/regulatory/licensing bodies.
• Interacts with internal and external personnel at all levels and effectively communicate risks, expectations, and alternative strategies to mitigate concerns over operational performance and program compliance.
• Actively collaborates and presents with Risk Partner and Business Unit executives in customer and regulator meetings (Insurance Department, HHS/CMS, Department of Health) on key risk and compliance related activities, issues, and remediation, promoting effective relationships. Manages teams conducting internal mock audits to ensure continuous audit preparedness, identifying opportunities for improvement and actions required, communicating results to business owners, and reporting results to management.
• Other duties as assigned or requested.
  
  

EDUCATION

Required

• Bachelor's Degree in Accounting, Finance, Business Administration/Management, Information Technology, Pre-Law, or related field
  
  

Substitutions

• 6 years of related and progressive experience in lieu of Bachelor's degree
  
  

Preferred

• Master's Degree in Accounting, Finance, Business Administration/Management, Information Technology, Pre-Law, or related field
  
  

EXPERIENCE

Required

• 5 years of interaction with regulators, auditors, and oversight bodies
  
  

To Include

• 3 years in in a leadership role, preferably in a Quality, Accreditation, Audit, or Compliance discipline in a Healthcare or Healthcare related industry
• 3 years overseeing quality, accreditation, audit, and/or compliance teams
  
  

Preferred

• None
  
  

LICENSES or CERTIFICATIONS

Required

• None
  
  

Preferred

• Certified Public Accountant (CPA)
• Lean / Six Sigma
  
  

SKILLS

• Demonstrate expert knowledge of business and technology processes, risk and control frameworks, and assessment methodologies, particularly as applied to healthcare (payer and provider) business processes
• Knowledge of relevant regulatory guidelines, vendor management, sourcing and procurement, and completing assessments of vendors
• Excellent resource and project planning capabilities, decision making skills, history of results-oriented delivery, and effective team building across a cross-campus and diverse team of management and staff
• Strong written and verbal communication skills for diverse audiences (senior management, board, peer, and team)
• Strong relationship building skills and ability to influence with and without authority in a matrixed organization
• Highly developed leadership qualities with an ability to motivate and inspire a group of individuals to achieve superior results.
• High capacity to think analytically, interpret information / observations, apply judgment and make effective, strategic decisions.
  
  

Language (Other Than English)

None

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Frequently

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting up to 10 pounds

Constantly

Lifting 10 to 25 pounds

Occasionally

Lifting 25 to 50 pounds

Rarely

Disclaimer The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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