Job Description

The Regulatory Specialist , SLA, is responsible for perform ing different tasks to ensure service level agreements and accreditation standards are complete . Essential Duties and Responsibilities: Collaborate with Quality Accreditation and Regulations team and leadership to assist in identifying quality issues and root causes and help to coordinate intervention plans Partner with the q uality team , network management, case management, member services , providers , etc., as well as external, (i.e., provider/designated group contacts ) in the evaluation, communication , outreach , and support of non-compliant members, providers, and groups P r ovide education and training for staff Compile various internal and external reports; obtain approval and distribute as necessary C ollect documents and reports from internal and external stakeholders Ensure that reports are analyzed and reported by responsible entities in a timely manner and in accordance with the NCQA activities calendar Partner, collaborate, develop, and support Regulatory Specialists within the Clinical Operations-Quality, Audit, and Risk department as follows: Care management and regulatory initiatives Create and maintain audit tools, reports, standardized policies, procedures, and manuals Assess survey readiness for NCQA accreditation and state and federal-based quality improvement compliance QI compliance-related activities are accomplished each year Direct compliance issues to appropriate channels for investigation and resolution Write, review, develop, revise, and maintain policies and procedures for the general operation of the Somatus compliance program and its related non-compliant activities ensuring they are in line with standards for accreditation, agency contract needs, and ongoing continuous quality improvement A cquire a thorough knowledge of each program and/or department operations and procedures Collect, c ompile, trend, and report quality data in the following areas: patient care, safety, risk management, infection control, outcomes, and customer satisfaction Investigate, manage, and analyze variances, incidents, and risk management data Comply with risk management-related standards for CMS, NCQA, and other accrediting agencies Complete credentialing packages and applications for new and current providers Resolve any issues related to provider credentialing Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice. Required Education and Experience: Bachelors degree in Nursing or other related fields Two ( 2 ) years of experience with NCQA Strong clinical background Knowledge, Skills, and Abilities : Possess an intermediate level of knowledge of local, state, and federal laws and regulations on guidelines of provider and/or healthcare care management Ability to document and analyze complex business requirements and processes Strong analytical skills Ability to be both a strategic and tactical change agent in the healthcare space Self-starter who will take initiative and be proactive when there are multiple priorities Strategic solution-seeker who sees opportunities when others see barriers Strong interpersonal skills and ability to communicate effectively Ability to handle ambiguity and desire to work in a fast-paced start-up environment Detail-oriented, accurate and complete work timely Ability to communicate in a courteous and professional manner with teammates, leadership, vendors , and others Proficient in MS Office Travel Requirement : This position may require up to 10 - 25% travel. Travel may be outside the local area and overnight. Physical Requirements : This job operates in a professional setting. While performing the duties of this job, the employee is regularly required to sit or stand for extended periods of time. Normal manual dexterity is required . Normal speaking and hearing abilities to interact with others in an office environment, over telephone or other video conferencing platform. The employee is occasionally required to stand; walk; and reach with hands and arms and continuously repeat the same hand, arm finger motion many times as in typing.

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