Onsite/Hybrid in Chicago
This position is responsible for creating, managing and reporting processes designed to monitor and evaluate activities and functions delegated to contracted, delegated entities and vendors for assigned products and business lines according to all corporate and regulatory/accreditation requirements and standards.
Job Responsibilities:
Develop, implement and manage processes and systems to monitor and evaluate all statewide delegated activities to groups, IPAs and vendors for PPO, POS and HMO products.
Establish and maintain pre-delegated and delegated oversight documentation (policies, procedures, audit tools, reporting formats, communication materials and scheduling) that is consistent with the intent of regulatory/accreditation requirements.
Maintain relationships with contacts at delegated groups to assure complete, timely and accurate communication regarding delegated functions and responsibilities.
Coordinate with key internal areas (Legal, HMO Compliance, Network Management, UM/QI, Finance) to ensure accurate and timely communication regarding the status of delegated groups, appropriate delegated contractual terms and pertinent information is distributed regarding new/revised regulations.
Keep abreast of current regulatory/accreditation requirements (Texas Department of Insurance, NCQA, URAC, NAC).
Review and evaluate mandatory delegated oversight reporting and follow processes to ensure timelines are met and information is disseminated throughout the organization for analysis, identification of opportunities to improve and incorporation of action plans, ongoing monitoring or de-delegation procedures as appropriate.
Participate in the management of member and provider complaints and appeals to assure appropriate resolution within established timeframes.
Schedule, organize and perform annual and other periodic onsite audits at delegated entity locations.
Provide formalized delegated oversight reporting as scheduled to appropriate committees and departments to facilitate communication of delegated oversight results and coordinate corrective action plans.
Maintain manuals documenting oversight agreements, delineation of responsibilities, reporting, audit results and key communications for each delegate.
Represent the department and division in meetings, committees and internal and external presentations.
Required Job Qualifications:
Associate Degree in Business or Medical OR 3 or more years experience in a managed care environment.
2 years in a leadership role that includes direct accountability and responsibility and direction of staff.
2 years experience in directly performing delegated oversight activities.
Project Management skills and experience.
Knowledge of regulatory/accreditation requirements and standards (TDI, NCQA, URAC).
Verbal and written communication skills.
Organizational skills and the ability to handle multiple priorities.
PC proficiency to include Word, Excel, PowerPoint and Lotus Notes.
Ability to travel (up to 30-40%) within Texas. Minimal travel outside of the state.
Preferred Job Qualifications:
Bachelor Degree in Business or Medical.
Knowledge of Power Point, Visio and Access.
College level courses or certification in project management.
Additional Responsibilities Required by All Client Employees:
Act with integrity and maintain a respectful, professional manner in all interactions with co-workers, management, customers and other business contacts
Comply with HIPAA, the Code of Business Ethics & Conduct, our Diversity & Inclusion Principles, and other applicable corporate and departmental policies
Maintain complete confidentiality in all matters of company business
Maintain communication with management regarding developments within areas of assigned responsibilities, and perform special projects as required or requested.