Job Description
Job Description
The Manager of QA (Quality Assurance) and Regulatory Policy will assist with the mission of ensuring our patients receive the highest quality care by producing meaningful outcomes for our patients and their families. This is accomplished through the alignment of all clinical programs, promotion of clinical standardization through policy, procedure, and training initiatives, and improvement of quality and safety while meeting and exceeding all applicable industry, federal, state, and payor requirements. Primarily the Manager of QA and Regulatory Policy will manage processes that support compliance with standards and regulations set forth by various external agencies and payors. The Manager will be the subject matter expert on medical necessity as well as lead the auditing and analysis of regulatory quality metrics, identify opportunities for quality improvement based on applicable industry, federal, state, and payor requirements, and document results of findings.
Responsibilities Essential Functions
Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions and other duties.
Regulatory Policy
- Maintains current and accurate knowledge of regulations, laws and standards including but not limited to external certification / licensure / accreditation boards, federal and state mandates, payor regulations, and generally accepted healthcare compliance standards that directly impact services offered by Hopebridge.
- Reads, interprets, and analyzes payor provider manuals / medical necessity criterion to ensure medical record templates, processes, and internal systems meet compliance standards.
- Maintain and update databases and other internal tracking systems with current regulatory standards.
Quality Assurance
Leverage the organization's information technology solutions and analytic environment to help guide data driven decision making, support and inform quality assurance and quality improvement initiatives.Direct activities that support compliance with voluntary, mandatory, and contractual reporting requirements for data acquisition, analysis, reporting, and improvement.Evaluates and implements changes to internal processes due to new or amended regulations.Creates and maintains a systematic process to discover quality assurance issues related to regulatory requirements, and works cross-functionally with all departments to resolve these issues.Analyzes denial data and trends (prior authorization and claims) and provides leadership regular reports and recommendations.Identifies, designs, and helps to implement processes and systems that improve performance related to prior authorization requests. Assists with validation and evaluation of new methodologies and system upgrades to analyze effectiveness of processes and programs and establishes on-going monitoring mechanisms.Communication and Training
Establishes communication and training initiatives that inform stakeholders about regulatory requirements, including but not limited to authorization requests and adverse determination, documentation requirements, medical necessity needs, and revenue cycle requirements.Develop targeted summary documents, internal guidance, position papers, training materials and communications to ensure leadership and staff are informed on regulatory compliance information, risks and trends, and how existing procedures might need to be amended to remain in compliance. Proactively communicates important changes and their potential impact.Creates a satisfactory working environment with other departments performing quality-assurance analyses, and assists with the accumulation, display, routing, and dissemination of information to appropriate persons and departments.Ensures quality related policies and procedures are monitored and updated to the standard of external certification / licensure / accreditation boards, payor regulations, and generally accepted healthcare standards.Required Skills Education and Experience
Master's degree in a related field preferred; BA / BS degree in healthcare / business administration, health information management, or related clinical field is required.The ideal candidate has several years' experience in the healthcare industry with a background in quality and regulatory compliance, and an understanding of complex organizations.Healthcare regulatory knowledge, spanning operational, compliance, and clinical aspects.Certified Professional in Healthcare Quality (CPHQ) preferred.Ability to communicate knowledge of Applied Behavior Analysis (ABA) to professionals and non-professionals preferred.Competencies
Working knowledge offederal and state mandates, legislative orders and directives, and payor regulations that impact access to autism treatment.Working knowledge in the areas of ABA therapy, Speech therapy, Occupational therapy, and autism.Excellent written and verbal communication skills.Ability to work on multiple tasks without sacrificing quality; meticulous attention to detail.Works independently, prioritizes responsibilities, and demonstrates excellent time management skills.Able to respond to change quickly and generate creative ideas and solutions to emerging business changes.Strong analytical and problem-solving skills, arranges information quickly and orderly and sees trends and relationships.Skill in researching, interpreting, and presenting data in a concise manner.Demonstrated leadership skills and relationship management.Culturally aware.Seeks opportunities to develop professionally in the areas of Autism and the law, quality assurance, and quality analysis.Other Duties
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.Position Type / Expected Hours of Work
This is a full-time position, Monday through Friday. Occasional evening and weekend work may be required as job duties demand.
Location and Travel
Location : Hopebridge Corporate Office, but remote employees with extensive experience may be considered.
For candidates in Indianapolis, IN : This position may require occasional travel (approximately 10%) to attend stakeholder meetings, which may include overnight travel.For remote candidates : In addition to the occasional travel indicated above (10%), travel to the home office monthly for multiple days is required (additional 20%), which may include overnight travel.Physical Demands :
Prolonged periods sitting at a desk and working on a computer.
Work Environment :
Work is performed in an office environment. Work may be stressful at times due to a busy office. Interaction with others is constant and interruptive.
Disclaimer
The above statements reflect genera / functionsof this job and shall not be construed as a detailed description of all work requirements inherent in this job. The immediate supervisor may elaborate on or add to the above list if the duties come within the employee's realm of responsibility.
Hopebridge is an Equal Opportunity Employer that does not discriminate on the basis of actual or perceived race, creed, color, religion, alienage or national origin, ancestry, citizenship status, age, disability or handicap, sex, marital status, veteran status, sexual orientation, arrest record orany other characteristic protected by applicable federal, state or local laws.
