Senior Compliance Auditor - Health Care - Member Appeals and Grievance
Company: Fallon Community Health Plan
Location: Worcester
Posted on: May 16, 2022
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Job Description:
Senior Compliance Auditor - Health Care - Member Appeals and
Grievances - Flex Remote!!US-MA-WorcesterJob ID: 6800Type: Full
Time# of Openings: 1Category: QualityFallon Health - Corp
HQOverview Fallon Health Vaccination Requirements: To protect the
health and safety of our workforce, members and communities we
serve, Fallon Health now requires all employees to disclose
COVID-19 vaccination status. As of 2/1/2022 all roles not
designated as "Remote" require full COVID-19 vaccination and Fallon
Health will obtain the necessary information from candidates prior
to employment to ensure compliance. Failure to meet the vaccination
requirement may result in rescission of an employment offer or
termination of employment. About Fallon Health Founded in 1977,
Fallon Health is a leading health care services organization that
supports the diverse and changing needs of those we serve. In
addition to offering innovative health insurance solutions and a
variety of Medicaid and Medicare products, we excel in creating
unique health care programs and services that provide coordinated,
integrated care for seniors and individuals with complex health
needs. Fallon has consistently ranked among the nation's top health
plans, and is accredited by the National Committee for Quality
Assurance for its HMO, Medicare Advantage and Medicaid products.
For more information, visit fallonhealth.org . Brief summary of
purpose: The Fallon Health Senior Compliance Auditor is an
essential function to Fallon Health's compliance with CMS
regulations, NCQA standards, otherapplicable regulatory
requirements and member expectations. The Senior Compliance Auditor
ensures adherence to the Fallon Health Appeals andGrievance process
as outlined in the Plan Member Handbook/Evidence of Coverage,
departmental policies and procedures, and regulatory standards.The
Senior Compliance Auditor serves to ensure that pertinent data
regarding member grievances and appeals is captured and entered
into theappropriate IT application, in compliance with the health
plan, governmental and accrediting agency requirements.
Responsibilities Primary Job Responsibilities: - Ensures adherence
to Fallon Health Standard and Expedited Appeals and Grievances
processes as outlined in Member Handbook/Evidence of Coverage, and
in compliance with applicable NCQA standards, CMS, MassHealth and
other state or federal regulatory requirements. - Leads and
represents Member Appeals and Grievances-related external CMS
audits, NCQA Standards, state audit and/or internal audit. -
Facilitates and completes internal dashboards and universes for
accuracy and timeliness. - Conduct audits on a regular basis
according to the policies and procedures as assigned by the
Director. Perform root cause analysis to ensure accuracy of
departmental processes and identify, when needed, process
improvement opportunities. Produce any necessary Corrective Action
Plans, Mitigation strategies and associated impact analysis. -
Through quality control and departmental audits, is responsible for
identifying gaps in our procedures as they relate to our internal
audit practices, and escalates concerns to management. Must have
the ability to analyze various situations and be able to make
independent decisions on best practices in the interest of the
members and the health plan to remain within compliance. -
Participates in various meetings as a department representative;
acts as a representative on various company wide committees.
Dessimates policies and procedure information to staff to ensure
successful functioning of the Department. Research and resolve
system-wide issues, deficiencies, problems and formulate quality
improvement measures. - Meet regularly with Department Director and
management team to identify and discuss department and/or
identified system issues directly effecting member and staff
satisfaction to recommend plans for improvement measures and in
developing and implementing specific work plans for improvements in
department work processes. - Propose and participate in training
based upon audit results and trending. Ensures operating manuals
and procedural documents stay current when regulations change. -
Performs other duties as they are assigned to meet department
performance goals and to respond to changing priorities including
administrative related tasks. Qualifications Education, Licenses,
certification and experience requirements: Education: Bachelor's
Degree preferred Experience: Five plus years' experience in managed
health care with appeal knowledge, and experience in internal and
external regulatory auditrequirements. Member Appeals and
Grievances Department preferred. Experience as a Member Appeals and
Grievances Coordinator preferred. Fallon Health provides equal
employment opportunities to all employees and applicants for
employment and prohibits discrimination and harassment of any type
without regard to race, color, religion, age, sex, national origin,
disability status, genetics, protected veteran status, sexual
orientation, gender identity or expression, or any other
characteristic protected by federal, state or local laws. PM16
PI
Keywords: Fallon Community Health Plan, Worcester , Senior Compliance Auditor - Health Care - Member Appeals and Grievance, Other , Worcester, Massachusetts
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