Director, Medical Regulatory and Accreditation

Job Summary - Director, Medical Regulatory And Accreditation

Collaborates with the VP and senior leadership of Priority Health's Medical Management and legal/compliance departments in the development, management, implementation and oversight of strategies, programs, and activities, to support operations for compliance with regulatory and accreditation requirements including Medicare, Medicaid, National Committee on Quality Assurance (NCQA), and other applicable federal and state regulations, statutes and codes.

Coordinates activities with external partners, such as health systems, delegated entities, and vendors in regard to regulatory and accreditation functions as those functions relate to Medical Management.

Supports activities and processes related to the medical policy life cycle.

Essential Functions - Director, Medical Regulatory And Accreditation

• Responsible for the development, management, implementation and oversight of strategies, programs, and activities to support operational compliance with regulatory and accreditation requirements and to ensure Medicare, Medicaid and NCQA audit readiness for the Medical Management department. This includes but is not limited to policies, program descriptions, audits/reviews for the department are appropriate, up to date and operationalized.
• Responsible for the annual risk assessments and mitigation strategies for Medical Management.
• Responsible to know, understand and monitor changes in applicable regulatory requirements and accreditation standards to evaluate impact for Medical Management strategies, policies, procedures, programs and functional operations, keeping the VP and senior leadership informed and providing support and guidance appropriately.
• Responsible for the oversight of efficient and effective operations for the end-to-end processes of medical policy review and implementation.
• Maintain open lines of communication with Health Plan Compliance Officers and be responsive and accountable as a key contact for required communications, actions, deliverables required for compliance audits, both internal and external, on behalf of Medical Management.
• Participate in Regulatory Oversight roles for Medical Management as assigned and be accountable for responsibilities as outlined in the Health Plan’s published regulatory organization and operations guidelines.
• Responsible for monitoring activities to demonstrate compliance with federal and state regulatory requirements and applicable NCQA accreditation standards, identifying issues timely and identifying and implementing education, training, process improvement and corrective action plans as necessary.
• Mentors, coaches, and develops direct reports, and acts as a role model and resource. Holds staff accountable for high performance against job descriptions, policies & procedures, controls, and processes, as well as organizational standards and policies. Completes performance reviews, commends, and initiates personnel actions such as interviewing, hiring, performance correction and terminations.
  
  

Qualifications - Director, Medical Regulatory And Accreditation

• Required Bachelor Degree in health care or business related field
• Preferred Master Degree
• 7 years of relevant experience in a health care related setting, preferably managed care or health insurance Required
• 5 years of relevant experience direct management of staff Required
• 7 years of relevant experience Applying project management or auditing methods or managing and implementing projects, processes, audits or related role.
  
  

Solid understanding of Medicare regulations, rules and guidelines or related State regulations Required

• #CH-LI
  
  

Physical Demands - Director, Medical Regulatory and Accreditation

• Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
• Waist to Waist > 5 lbs: Seldom up to 10 lbs
• Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
• Waist to Overhead > 5 lbs: Seldom up to 10 lbs
• Bilateral Carry > 5 lbs: Seldom up to 10 lbs
• Unilateral Carry > 5 lbs: Seldom up to 10 lbs
• Pushing Force > 5 lbs: Seldom up to 10 lbs
• Pulling Force > 5 lbs: Seldom up to 10 lbs
• Sitting: Frequently
• Standing: Occasionally
• Walking: Occasionally
• Forward Bend - Standing: Seldom
• Forward Bend - Sitting: Occasionally
• Trunk Rotation - Standing: Seldom
• Trunk Rotation - Sitting: Occasionally
• Reach - Above Shoulder: Seldom
• Reach - at Shoulder or Below: Seldom
• Handling: Occasionally
• Forceful Grip > 5 lbs: Seldom
• Forceful Pinch > 2 lbs: Seldom
• Finger/Hand Dexterity: Frequently
  
  

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance, pet insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status
  
  

Primary Location

SITE - Priority Health - 1231 E Beltline - Grand Rapids

Department Name

PH - Medical Management

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8:00 a.m. to 5:00 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

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Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.