Sr. Mgr. Compliance - Continuing Care (Utilization Review)

Kaiser Permanente

  • Hyattsville, MD
  • Permanent
  • Full-time
  • 2 months ago
Sr. Mgr. Compliance – Continuing Care (Utilization Review)Location: Mid-Atlantic States (D.C., Maryland, Virginia)Position Overview: The Senior Manager, Compliance will oversee and ensure adherence to regulatory requirements and internal policies within the health plans specific to utilization review, and compliance functions. This role involves collaborating with various agencies and stakeholders to maintain compliance standards and improve operational efficiency.The Sr Mgr., Compliance will oversee utilization review processes to ensure appropriate use of healthcare services and resources. They will develop, implement, and update compliance policies and procedures, lead the UM components of compliance audits and monitoring activities to identify and mitigate risks, provide training and education to staff.They will work closely with government, regulatory, and accreditation bodies, such as Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS), State Health departments in D.C., Maryland, and Virginia, National Committee for Quality Assurance (NCQA), Maryland Health Care Commission (MHCC), Managed Care Plans (MCP), and others, and internal departments to ensure compliance and operational excellence.Job Summary:This senior manager level position is primarily responsible for managing company compliance activities in partnership with internal and external stakeholders and managing strategic compliance initiatives. Responsibilities include managing compliance reporting efforts, compliance investigation, and activities associated with continued regulatory compliance across one or more business functions. Additional key responsibilities include managing the implementation of compliance efforts through monitoring, interpreting, and designing strategy around regulatory changes. This managing level employee also manages projects or compliance components of larger cross-functional projects including identifying and managing stakeholders.Essential Responsibilities:
  • Pursues professional growth and provides developmental opportunities for others by soliciting and acting on performance feedback; building collaborative, cross-functional relationships; hiring, training, and developing talent for growth opportunities; delegating tasks and decisions; fostering open dialogue amongst departments; strategically evaluating talent for succession planning; setting performance management guidelines and expectations across units; and working closely with employees to set goals and provide open feedback and coaching to drive performance improvement.
  • Manages designated units by translating business plans into tactical action items; communicating goals and objectives; ensuring all policies and procedures are followed; overseeing the completion of work assignments; assuming responsibility for decision making; aligning team efforts; building accountability for and measuring progress in achieving results; incorporating resources, costs, and forecasts into unit plans; removing obstacles that impact performance; guiding performance and developing contingency plans accordingly; partnering with key stakeholders and business leaders to ensure products and/or services meet requirements and expectations while aligning with departmental strategies; and influencing units to operate in alignment with business objectives.
  • Manages company compliance activities by partnering with internal and external stakeholders; applying established regulations and standards to compliance efforts; managing the design, development, and execution of strategic compliance initiatives; overseeing the analysis of regulations and regulatory changes, and their application to operations; and overseeing the documentation of compliance activities.
  • Manages compliance reporting efforts across one or more business functions by managing the evaluation and summary of compliance data, audit information, and potential risks and remedies; identifying and reporting key compliance drivers, liabilities, and performance indicators (for example, adherence to standards, incorporation of new regulations) to senior management; and developing complex presentations to convey key findings to leadership and external business stakeholders.
  • Manages compliance investigations across one or more business functions by managing the collection and analysis of quantitative and qualitative data; leading interviews as appropriate; researching key business issues; and evaluating and recommending corrective action plans for substantiated allegations.
  • Manages projects or compliance components of larger cross-functional projects by identifying and managing stakeholder contacts; assembling teams based on project needs and team member strengths; developing, analyzing, and managing project plans; negotiating and managing project schedules and resource forecasts; and managing project financials and deliverables.
  • Manages activities associated with continued regulatory compliance for one or more business functions by monitoring, interpreting, and designing strategy around regulatory changes; determining the impact of changes to the business; providing direction on implementation of changes throughout the organization; and providing regulatory input before and during inspections to minimize the risks of future non-compliance.
  • Manages the implementation of compliance efforts by approving compliance requirements; ensuring the assessment of current state compliance to identify gaps and corrective actions; managing the analysis and development of complex compliance standards, policies and procedures, and training; and ensuring and monitoring ongoing compliance adherence.

Kaiser Permanente