Job Description

Please email hr_business_partners@bcbsri.org if you are a candidate seeking a reasonable accommodation for the application and/or interview process.

Schedule: Hybrid or Remote
Compensation: $69,800 - $104,800

Jump into the new world of health insurance:
At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.

Join others who know diversity is strength:
We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.

Why this job matters:
Develop, implement, and monitor compliance plans based on state and federal regulations and any applicable accreditation standards and renewal activities. Assist in the overall implementation of clinical programs that comply with government regulations and meet the needs of our members in government plans that require significant clinical interventions. i.e., Medicare special needs plans, Medicaid. Assist with implementation and maintenance of Mental Health Parity compliance program. Evaluate regulations, educate affected staff, and conduct periodic clinical audits of operational areas and delegated organizations to ensure effective ongoing regulatory and accreditation compliance.

What you will do:

• Develop, implement, and monitor regulatory compliance plans and strategies including evaluation of state and federal regulations, applicable accreditation standards, assessments of organizational and delegated organizations\xe2\x80\x99 compliance with clinical requirements, preparation of reports for senior management and various internal committees, review of corporate and delegated organizations\xe2\x80\x99 policies, procedures, reports, and self-monitoring activities. Conduct periodic and/or focused audits of work performed by business units and delegates with regulatory or accreditation accountabilities. Develop and maintain effective audit tools designed to measure performance against applicable regulatory and accreditation requirements.
• Support quality initiatives through collaboration with internal and external partners/vendors and assist in the identification, tracking, analysis, and reporting of metrics.
• May serve as a primary point of contact for state regulators or delegated vendors as it pertains to regulatory Medicaid and D-SNP communications. May serve as clinical liaison to business areas to ensure successful partnership, high quality, and daily activities are achieved.
• Maintain a thorough and comprehensive understanding of Medicare local and national coverage determinations, CMS regulatory requirements and sub regulatory guidance, Mental Health Parity, NCQA standards, and State of RI utilization review regulations in order to audit and monitor the appropriateness of clinical decision making by internal business units and delegates.
• Maintain a thorough and comprehensive understanding of plan business practices to assess the impact of regulatory requirements and accreditation standards, assist with the review and revision of policies and procedures as related to accreditation standards, provide education to affected staff.
• Educate plan and delegated vendor staff as necessary regarding regulatory requirements and compliance activities. Assist corporate and delegated vendor staff in the development of policies and procedures to comply with regulatory requirements. Maintain accurate and comprehensive documentation of compliance activities as needed to meet or exceed requirements of external audits.
• Complete performance reviews related to adherence of NCQA and Mental Health Parity and other applicable accreditation standards. Ensure appropriate documentation to demonstrate adherence.
• Assist in conducting pre-delegation assessments of potential new delegates. Represent department on multi-departmental workgroups as needed.
• Prepare submissions to regulatory and accreditation agencies and related documentation as required to receive agency approvals or in response to agency requests, coordinate on-site audits conducted by regulators/accreditation agencies as necessary.
• Perform other duties as assigned.

What you need to succeed:

• Three to five years in health care regulatory compliance activities or health plan operations
• Strong understanding of health care compliance programs
• Experience in Utilization Management and/or Case Management processes
• Experience conducting audits.
• Knowledge of National Committee for Quality Assurance accreditation requirements and guidelines
• Knowledge of Mental Health Parity
• Knowledge of Utilization Review Accreditation Commission requirements and guidelines
• Knowledge of CMS and RI state laws governing utilization review
• Ability to maintain confidentiality.
• Broad knowledge of compliance principles, practices, and procedures
• Advanced analytical skills, with the ability to interpret and synthesize complex data sets.
• Excellent verbal and written communications skills
• Excellent organizational skills and ability to successfully prioritize multiple tasks.

The Extras:

• Healthcare Compliance Certification (CHC), Compliance & Ethics Professional Certification (CCEP), Healthcare Research Compliance Certification (CHRC)

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia

At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today\'s healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.
The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit https://www.eeoc.gov/employers/eeo-law-poster to view the "EEO is the Law" poster.