Description

Hourly Pay Range: $35.59 - $51.60

Job Summary

Under the direction of the Provider Services Quality & Network Development Manager, the Quality & Regulatory Liaison is responsible for the development and implementing initiatives that improve access to high-quality care for members, support provider satisfaction, and ensure compliance with regulatory and contractual requirements. The primary responsibilities of this position include, but are not limited to:

• Coordinating network satisfaction and improvement initiatives

• Collaborating cross-functionally to ensure regulatory compliance

• Leading various projects to ensure the completion of departmental and organizational goals

• Other duties as assigned

Duties and Responsibilities

1. Coordinating network satisfaction and improvement initiatives, with duties including but not limited to:

• Administering surveys, analyzing data, preparing reports, and sharing findings with various audiences. Identifying issues and trends requiring follow-up and opportunities for improvement. Assisting in developing and implementing corrective actions based on survey results.

• Leading quality and performance improvement projects that promote member access to care. Building partnerships with providers to develop a team approach to higher-quality outcomes. Developing innovations to enhance provider engagement and reduce administrative burdens for providers.

• Acting as a liaison for various vendors and delegates. Coordinating communication, meetings, and data exchange between CenCal Health and these entities.

2. Collaborating cross-functionally to ensure regulatory compliance, with duties including but not limited to:

• Interfacing with various internal staff, including but not limited to: Claims, Compliance, UM, Credentialing, Legal, Administration, and Finance.

• Reviewing All Plan Letters (APLs) to determine department and/or network impact. Coordinating and conducting Provider Services response/activities to comply with APLs as needed.

• Evaluating regulatory and contractual requirements as they relate to the provider network, including but not limited to network adequacy, timely access, provider data, and quality care.

• Assisting in the preparation and timely filing of recurring and ad-hoc reports required to be submitted to the state Department of Health Care Services (DHCS), Center for Medicare & Medicaid Services (CMS), and other agencies.

• Coordinating the internal information gathering and preparation as may be required during audits or other requests from regulatory agencies.

• Preparing responses to comment letters and audit findings from regulatory agencies within the timeframes dictated by those agencies.

• Assisting in the development and maintenance of policies and procedures consistent with regulatory and state contract requirements and current industry standards.

• Assisting in the implementation of Provider Services audit processes to ensure compliance with federal and state statutes and regulations.

3. Leading various projects to ensure completion of departmental and organizational goals, with duties including but not limited to:

• Attending meetings as the Provider Services representative to determine action items and next steps for the department.

• Responsible for holding kick-off meetings, obtaining all project details, and developing, revising, and executing work plans to ensure timely and efficient completion of assigned projects.

• Coordinating clear and timely communication with internal stakeholders regarding the scope, schedule, and resources of the project.

• Assisting with tracking tasks, timelines, and resources to achieve desired project objectives.

• Responding to inquiries related to project activities.

• Assisting with or leading the development and execution of communication strategies based on the audience.

4. Other duties as assigned

Qualifications

Knowledge/Skills/Abilities

• Ability to conduct research, develop and organize project work plans, and maintain accurate records

• Excellent communication skills, including oral, written, and presentation skills

• Strong interpersonal skills with the ability to interact with all levels of management, staff, and providers

• Strong computer software skills (including proficiency in MS Windows Word, Excel, and PowerPoint applications)

• Knowledge of the principles and practices of project management

• Self-starter with the ability to work remotely, be accountable, and maintain relationships

• Self-motivated with a positive and professional approach

Desired:

• Familiarity with Medicaid (Medi-Cal), Medicare, and other publicly funded programs

• Knowledge of the healthcare industry and the principles of healthcare planning

Education and Experience

• Bachelor’s degree in health science, health administration, or other related field or the equivalent combination of education and relevant experience

• Two (2) years’ of health care experience, with a minimum of one (1) year experience in managed care