This is a remote role and can be done in most US states.

The Clinical Quality Compliance Specialist will be responsible for overseeing delegated vendor(s) for Coverage Determinations Appeals and Grievances and Organization Determinations Appeals and Grievances for the Medicare line of business. This role will ensure compliance with all Centers for Medicare and Medicaid (CMS) CDAG and ODAG regulations. Through daily, monthly, and quarterly reporting and auditing, this role will confirm each aspect of CDAG and ODAG are meeting CMS requirements. This role will work closely and coordinate operations with other departments to assist in collaboration where CDAG and ODAG work overlaps. This position will develop and maintain policy and procedures for investigating samples, identifying any areas of concern or gaps in vendor processes. As part of vendor oversight this role will also work with the Compliance team to develop reporting and further action required related to any corrective action plans or any areas of non-compliance identified. This position will be the point person in assisting with any audits involving CDAG and ODAG, ensuring audit universes are complete and accurate. Overall, this role will include independent research, data analysis, documentation, and program oversight while ensuring compliance with all CMS and state regulations related to applicable Medicare product lines.

Principal Duties and Responsibilities:

* Review daily, weekly, monthly, quarterly, and yearly CDAG and ODAG reporting to ensure compliance with all Centers for Medicare and Medicaid (CMS) requirements.

* Develop and maintain CDAG and ODAG reporting for internal teams as well as external auditors

* Perform data analysis to identify areas of potential non-compliance or gaps and collaborate with delegated vendor to update Policies and Procedures

* Perform periodic, targeted auditing of coverage determination cases, appeals and grievances for Part D

* Perform periodic, targeted auditing of organization determination cases, appeals and grievances for Part B

* Perform frequent data validation to ensure vendor(s) are providing accurate data within reporting and audit universes

* Ensure internal auditing includes reviews of all reportable pieces of CDAG and ODAG cases including but not limited to:

* accuracy of time stamping

* appropriateness of case decision(s)

* compliance of turnaround times (TATs) for the situation

* correct letters are attached for specific case situation/decision

* Provide internal case summaries for any cases forwarded to Independent Review Entities (IRE)

* Perform oversight of any corrective action plans (CAPs) of delegated vendors and develop additional monitoring to ensure issues are remediated

* Coordinate the identification impacted members

* Develop and oversee the distribution of any required member or provider notification

* Collaborate and align with internal teams for any coordination of care processes to maximize member experience and provide excellent care

* Monitor delegated vendor for clinical criteria updates and track implementation of changes

* Develop and maintain tracking grids of all criteria updates within CDAG and ODAG systems

* Collaborate with internal Clinical Pharmacy and Utilization Management teams for presentation and approval of updated clinical criteria to applicable committees according to CMS requirements and timeframes

* Develop enhanced processes and implement best practices to for members across the Part D and Part B benefits

* Perform quarterly and yearly data analysis to identify trends and collaborate with Clinical Pharmacy and Utilization Management teams on future strategies

* Develop and ensure all required CDAG and ODAG related documentation is posted on the website and available for print as required and updated accordingly

* Serve as the liaison and point of contact between internal teams and the CDAG and ODAG vendor(s)

* Participate as CDAG and ODAG representative in audits as necessary

* Collaborate with CDAG and ODAG vendors to implement any new guidance as CMS requires

* Oversee yearly implementation of new contract year CDAG and ODAG processes including but not limited to:

* Yearly loading of updated clinical criteria

* Application of new guidance and CMS requirements

* Developing and posting of member materials

* Monitor CMS CDAG and ODAG requirements for updates and changes and oversee implementation of these updates according to CMS

* Develop and maintain tracking grids for any criteria updates including effective dates

* Hold self and others accountable to meet commitments.

* Ensure diversity, equity, and inclusion are integrated as a guiding principle.

* Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.

* Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.

* Other duties as assigned with or without accommodation.

Qualifications:

* Bachelor's degree in related field required or the equivalent combination of training and experience, plus minimum of three years of Medicare ODAG and CDAG related experience.

* Minimum of three years' experience in managed care.

* Managed care with a strong focus on Medicare CDAG and ODAG related experience.

* Experience with benefit and drug coding logic for case reviews.

* Experience with MAPD, PDP, Employer Group and Dual-Eligible Plans.

* Experience with CMS Medicare audits.

Skills/Abilities/Competencies:

* Proficiency in Microsoft Word and Excel.

* Demonstrate Mass General Brigham Health Plans core brand principles of always listening, challenging conventions, and providing value.

* Bring fresh ideas forward by listening to and working with employees and the people we serve.

* Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner.

* Strong, demonstrated track record of an ability to execute on time, on budget, and on scope.

* Strong aptitude for technology-based solutions.

* Ability to inject energy, when and where it's needed.

* Current in healthcare trends.

* Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be."

* Ability to develop, introduce, defend, and gain support for a new ideas and approaches.

* Excellent leadership skills and leadership track record.

* Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills. Strong verbal, active listening, and written communication skills required.

* Ability to view the long-range trends and cycles of the business and industry and see the "big picture."

* Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.

* Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.

* Excellent interpersonal skills, including the ability to influence others at all levels of an organization.

* Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.

* Unquestionable integrity.