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Please note that effective Jan. 4, 2022, Blue Cross and Blue Shield of Louisiana will require all employees to be fully vaccinated for COVID?19, unless legally entitled to a reasonable accommodation related to religious or medical exemptions.
POSITION PURPOSEThis Divisional Compliance Consultant will be responsible for managing and/or coordinating departmental activities to ensure compliance with new and existing laws, regulations, and requirements. This role will be focused on ensuring that all aspects of the Provider Data Management team are compliant with BCBSA, CMS, NCQA, URAC, and state and federal laws.
NATURE AND SCOPE- This role does not manage people
- This role reports to this job: MANAGER, PROVIDER DATA INTEGRITY
- Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with:
All levels of BCBSLA personnel; all personnel level for delegated entities contracted by the Plan for network and/or credentialing activities, URAC; NCQA and other accrediting agencies, including Medical Directors, Vice Presidents, and other management; The incumbent will be the primary point of contact for Network Development and Provider Credentialing accreditation activities; responsible for participation in all delegation outreach and onsite review of delegated vendors as appropriate.
QUALIFICATIONS
Education- Bachelor's degree in business or a related field is required
- Four years of related experience can be used in lieu of a Bachelor’s degree.
Work Experience- 2 years of experience in compliance or regulatory affairs is required.
- Project management skills are required
Skills and Abilities- Excellent analytical, planning and problem-solving skills are required.
- Requires the ability to successfully interface with individuals at all levels, including top management, both internal and external.
- Knowledge of regulatory requirements such as experience with CMS and state regulatory and accreditation requirements preferred.
- Experience in healthcare or health insurance is strongly preferred.
- Some experience in consultative/advisory role is preferred.
- Ability to travel may be required.
Licenses and CertificationsACCOUNTABILITIES AND ESSENTIAL FUNCTIONS- Serves as point of contact, coordinating and collaborating with regulatory bodies and business partners to ensure compliance with regulatory, accrediting and delegated provider relationships.
- Assists with the interpretation of applicable laws and regulations.
- Develops tools that assist in determining exposure to regulatory and/or accreditation risks.
- Identifies opportunities to manage and mitigate those risks.
- Works with business management areas to develop metrics for monitoring program objectives and policies and procedures that support compliance with regulatory and accreditation standards.
- Compiles information related to quality improvement and compliance monitoring activities for internal use and external audits and maintains relevant records.
- Conduct risk assessments and/or audits and monitor department/divisional systems for compliance. Ensure appropriate implementation and/or corrective action is taken to address risks and issues identified in partnership with
- Corporate Compliance.
- Monitors corrective action plans relating to regulatory or accreditation compliance.
- Makes recommendations to business unit partners for improvements or remediation to risk management, regulatory, and accreditation compliance programs.
- Monitors development and use of metrics for regulatory compliance.
- Monitors business unit initiatives relating to the development and implementation of a risk management program for utilization management activities.
- Ensures that necessary controls are in place to monitor the effects of new functionality, and communicates status and changes to affected parties.
- Manage and/or facilitate departmental/divisional implementation and remediation of compliance initiatives in conjunction with Corporate Compliance.
- Creates audit tools, reports, standardized policies and procedures, and manuals.
- Facilitates implementation of survey or regulatory recommendations.
- Recommends new processes.
Additional Accountabilities and Essential Functions
The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions- Perform other job-related duties as assigned, within your scope of responsibilities.
- Job duties are performed in a normal and clean office environment with normal noise levels.
- Work is predominately done while standing or sitting.
- The ability to comprehend, document, calculate, visualize, and analyze are required.
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An Equal Opportunity Employer
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