Vacancy expired!
This is a remote opportunity. Note, quarterly/ad-hoc/situational on-site requirement in Brooklyn, Ohio. Eastern Time Zones preferred.ResponsibilitiesOperations Compliance Specialist-Medicare AdvantageActs as a subject matter expert and collaborates with various internal departments to ensure that the Medicare Advantage (MA) Customer Care practices, procedures, and regulatory reporting are compliant with CMS guidance, improves quality and operational efficiency, and enhances satisfaction for members. Develops and maintains policies and procedures and Corrective Action Plans (CAP) to align with CMS guidance and to address deficiencies or issues identified in the internal monitoring process. Oversees external vendor (FDR) to assure delegated entities maintain compliance with contracts and applicable CMS guidance.· Maintains knowledge of and interprets CMS managed care guidance. Develops and maintains policies, procedures, learning materials, documentation, and SharePoint sites to maintain MA compliance. Collaborates across departments to assure consistency with CMS guidance, applicable Stars measures and other related requirements. Informs MA staff of updates to CMS guidance and related policies and procedures.· Monitors internal and delegated requirements (e.g., ODAG and CDAG) for compliance with CMS reporting specifications. Resolves areas of non-compliance; develops and monitors CAP in response to issues or deficiencies identified during internal monitoring. Reports findings to management and MA Compliance. Ensures audit ready preparedness for both annual and ad-hoc audits with CMS.· Works across departments and divisions on various projects and committees to reduce the risk of non-compliance. Represents Customer Care in audits, committees, and MA Compliance activities.· Performs ad hoc monitoring to verify compliance and identify training needs. Assists in the development and maintenance of MA learning materials and process workflows as a result of these audits or other trends identified.· Oversees external vendors (FDRs) regarding delegated responsibilities per signed contracts. Monitors FDR processes for compliance with contract and any applicable CMS guidance. Resolves any areas of non-compliance including development and monitoring of CAPs with FDRs. Reports findings to CQHS management and MA Compliance via presentations and Dashboard. Informs FDRs of updates to CMS guidance and related processes and procedures.· Performs other duties as assigned.Senior Operations Compliance Specialist-Medicare AdvantageUnder limited supervision, acts as a subject matter expert and collaborates with various internal departments to ensure that the Medicare Advantage (MA) Customer Care practices, procedures, and regulatory reporting are compliant with CMS guidance, improves quality and operational efficiency, and enhances satisfaction for members. Develops and maintains policies and procedures and Corrective Action Plans (CAP) to align with CMS guidance and to address deficiencies or issues identified in the internal monitoring process. Oversees external vendor (FDR) to assure delegated entities maintain compliance with contracts and applicable CMS guidance.· Works across departments and divisions and may lead various projects and committees to reduce the risk of non-compliance. Represents Customer Care in audits, committees, and MA Compliance activities.· Performs ad hoc monitoring to verify compliance and identify training needs. Develops and maintains MA learning materials and process workflows as a result of these audits or other trends identified. Facilitates training sessions as needed.· Maintains knowledge of and interprets CMS managed care guidance. Develops and maintains policies, procedures, learning materials, documentation, and SharePoint sites to maintain MA compliance. Collaborates across departments to assure consistency with CMS guidance, applicable Stars measures and other related requirements. Informs MA staff and management of updates to CMS guidance and related policies and procedures.· Monitors internal and delegated requirements (e.g., ODAG and CDAG) for compliance with CMS reporting specifications. Resolves areas of non-compliance; develops and monitors CAP in response to issues or deficiencies identified during internal monitoring. Reports findings to management and MA Compliance. Ensures audit ready preparedness for both annual and ad-hoc audits with CMS.· Oversees external vendors (FDRs) regarding delegated responsibilities per signed contracts. Monitors FDR processes for compliance with contract and any applicable CMS guidance. Resolves any areas of non-compliance including development and monitoring of CAPs with FDRs. Reports findings to CQHS management and MA Compliance via presentations and Dashboard. Informs FDRs of updates to CMS guidance and related processes and procedures.· Performs other duties as assigned.QualificationsOperations Compliance Specialist-Medicare Advantage· Bachelor’s degree in business administration, health care administration, health policy, or finance.· In lieu of degree may consider equivalent combination of education/training and experience.· 3 years of experience with health insurance operational or compliance audits which includes Medicare/Medicaid or related experience in the financial services or healthcare industry.· Certification in health plan government programs a plus (required to obtain within 6 months of hire).· Six sigma or project management certification a plus.· Strong continuous process improvement skills which include root cause analysis, risk identification and corrective action planning.· Strong knowledge of CMS managed care guidance, legal definitions, and other Medicare requirements.· Knowledge of project management principles.· Ability to make presentations to compliance committee or leadership on regulatory changes or trends.· Intermediate to advanced Microsoft Office skills.· Strong knowledge of health insurance operations.· Ability to write policies, procedures, and corrective action plans.Senior Operations Compliance Specialist-Medicare Advantage· Bachelor’s degree in business administration, health care administration, health policy, or finance.· In lieu of degree may consider equivalent combination of education/training and experience.· 5 years of experience as an Operations Compliance Specialist – MA or equivalent experience with health insurance operational or compliance audits which includes Medicare/Medicaid.· Certification in health plan government programs a strongly preferred (required to obtain within 6 months of hire).· Six Sigma or project management certification preferred.· Strong continuous process improvement skills which include root cause analysis, risk identification and corrective action planning.· Strong knowledge of six sigma and/or project management principles.· Strong knowledge of CMS managed care guidance, legal definitions, and other Medicare requirements.· Ability to make presentations to compliance committee or leadership on regulatory changes or trends.· Advanced Microsoft Office skills.· Strong knowledge of health insurance operations.· Ability to write policies, procedures, and corrective action plans.Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:A Great Place to Work:
Top Workplace in Northeast Ohio. Year after year we've received this recognition!
On-site wellness center at most locations. Enjoy personal trainers, towel service, locker room, weight room, elliptical machines, and a variety of classes!
On-site cafeteria serving hot breakfast and lunch, at most locations. Choices ranging from salad bar, made to order, hot and cold sandwiches, or a variety of entrees cooked fresh daily. Convenience store at most locations
Employee discount program. Discounts at many places in and around town, just for being a Medical Mutual team member
Business Casual attire
Excellent Benefits and Compensation:
Competitive compensation plans
Employee bonus program
401(k) with company match and an additional company contribution
Excellent medical, dental, vision, and disability insurance
An Investment in You:
Career development programs and classes
Mentoring and coaching to help you advance
Education reimbursement up to $5K per year
About Medical Mutual:We strive to create peace of mind. Our customers can trust us to do things right and to help them get value from their health plan. We're the largest health insurer in Ohio and for over 85 years, we've been serving our members and the Ohio communities where they live and work. Medical Mutual is a Top Place to Work in Northeast Ohio with exceptional career opportunities that offer challenge, growth and a great work/life balance. We want talented, innovative, and driven people to help us continue to be the best health insurance choice of Ohioans and help make Ohio the best it can be! Our headquarter building is located in the heart of downtown Cleveland and we have multiple offices throughout the state. Join us at one near you!At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.Title: Operations Compliance Specialist-Medicare AdvantageLocation: OH-BrooklynRequisition ID: 2400016
Full-time