Highmark Health

Manager Risk & Quality Assurance

Highmark Health

full-time

Posted on:

Origin:  • 🇺🇸 United States • New York, Pennsylvania

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Job Level

Mid-LevelSenior

About the role

  • 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.
  • 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. 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.

Requirements

  • 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
  • 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
  • LICENSES or CERTIFICATIONS Required: None
  • 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