Baltimore City County, Maryland, United States
Provides compliance support and oversight to operational partners regarding proactive initiatives and reactive inquiries from regulators, employer groups and members. In collaboration with the legal department, interprets and analyzes regulations affecting contracts for health plan products, provider contracts and credentialing requirements Coordinates regulatory filings with regulatory agencies Coordinates external audits from state regulatory boards, and follows up for appropriate corrective actions on deficiencies identified Serves as an internal business consultant to medical facility management to ensure compliance with policies and procedures. Conducts internal investigations and audits. Reviews regulations (e.g. to determine impact on applicable operational areas). Designs and develops monitoring systems and strategies, (beyond the national compliance tracking system) to facilitate the timely implementation of corrective action plans. Work with Program Managers and other compliance staff to investigate allegations of violations of the principles of responsibility, privacy and security, and other internal or external compliance related violations. Help achieve and maintain compliance with HIPAA.
Established effective means of interdepartmental communication and coordination of compliance issues and activities both directly and through the appropriate committee structures by serving as the compliance representative on any existing committees or workgroups within health plan, health care delivery, including and other workgroups. Coordinated and communicating strategies and directions from policy makers to facility management to ensure open two-way communication Communicated and provided business update to operational department managers, staff and executive leadership Audited and assessed facility operations as it pertains to healthcare compliance, and other health plan product compliance regulations Recommended and assisted in implementation of new procedures and best practices to improve efficiency and compliance. Monitored corrective action plans in place within the medical centers. Helped achieve and maintain compliance with HIPAA.
Acted as a liaison between business and technical team to obtain detailed Functional, Business requirements, users Requirements and Business rules that will help make the system development easier for the technical team. Collaborated with developers and subject matter experts to establish the technical vision and analyze tradeoffs between usability and performance needs. Provided reports on projects scheduled to the project manager as well as supported other team members to ensure project success. Independently interacted regularly with clients of varying associate management levels to gather and analyze business requirements and interpret solutions, business needs and issues in order to design solutions that would solve technical and business issues. Developed a new process for employee evaluation, which resulted in marked performance improvements.