Director, Compliance and Quality Oversight
CareOregon
- Portland, OR
- $135,198-165,242 per year
- Permanent
- Full-time
- Develop, execute and oversee a compliance plan which includes risk assessment and monitoring of internal activities related to execution of the Health Plan Services Contract with the Oregon Health Authority.
- Identify and evaluate risk factors relative to Health Share's compliance and program integrity obligations; identify potential areas of compliance vulnerability and ensure corrective action to reduce or mitigate these risks.
- Identify and evaluate potential risk factors in delegating regulated functions; ensure corrective action to reduce or mitigate these risks.
- Develop, implement and oversee program integrity functions, including prevention and detection of fraud, waste and abuse; respond promptly to potential instances of fraud or abuse, reporting to appropriate state and federal agencies.
- Develop and implement company training and education program related to program integrity and compliance.
- Effectively collaborate with the Privacy and Security Officer on compliance related issues.
- Lead quality assurance strategies and planning; oversee implementation and effectiveness.
- Participate in the development and oversight of cross-functional initiatives with accountability for components related to quality of care, grievance system, and program integrity.
- Develop, update and revise policies and procedures related to areas of accountability.
- Provide oversight and direct staff in implementing processes for delegation and quality oversight including care and utilization management, quality assurance, performance improvement, and program integrity.
- Perform work in alignment with the organization's mission, vision, and values.
- Support the organization's commitment to equity, diversity, and inclusion by fostering a culture of open mindedness, cultural awareness, compassion, and respect for all individuals.
- Strive to meet annual business goals in support the organization's strategic goals.
- Adhere to the organization's policies, procedures, and other relevant compliance needs.
- Perform other duties as needed.
- Advanced knowledge of Federal and State regulations related to Medicaid and ability to interpret and communicate these requirements
- Advanced knowledge of principles, practices, procedures and professional standards associated with compliance and quality assurance program management and techniques for evaluation of program effectiveness
- Extensive knowledge of managed care and the Oregon Health Plan
- Ability to obtain and retain knowledge of
- government regulations as they relate to the administration of OHP and Medicare
- the principles and practices of coordinated care
- health plan benefits, systems and procedures, changes in guidelines and regulations, changes in the health care services, changes in the legal/legislative arena that impact operations
- health care public policy issues
- Excellent verbal and written communication skills, including the ability to persuade, influence, negotiate and make formal presentations
- Ability to analyze and solve problems, prioritize, organize and manage multiple tasks
- Adept at utilizing various approaches to achieve consensus, achieve favorable outcomes, manage change and influence others
- Ability to work effectively with diverse internal and external stakeholders
- Ability to oversee or manage multiple complex projects concurrently, ensuring effective use of resources and achievement of outcomes
- Ability to perform repetitive finger, wrist, shoulder, or neck movement for at least 8 hours/day
- Ability to see, read, hear, and speak clearly for at least 8 hours/day
- Ability to focus on and comprehend information and learn new skills and abilities
- Ability to assess a situation and seek or determine appropriate resolution
- Ability to accept direction and feedback, as well as tolerate and manage stress
- Minimum 8 years' experience in related work, including 4 years' experience in Medicaid/Medicare compliance and quality assurance experience
- Minimum 4 years' experience in a supervisory position
- Compliance and quality assurance experience in a managed care setting