RN Senior Manager, Regulatory Operations - 1135457 (21312750)
Manage operations of clinical contract compliance aspects of the medical management, care management and quality management requirement of the Medicaid contracts, including the review and development of the medical management (MM) and quality management (QM) plans. Oversee child and family team fidelity reviewers and team that is responsible for Medicaid deliverable submissions.
- Oversee the staff conducting onsite provider audits to determine adherence to evidence based practices, ensuring audit findings, recommendations for modifications and improvements to operations, systems and procedures are made timely.
- Ensure defined goals are implemented and relevant analytics are available to measure evidence based practices and corrective actions are implemented to ensure compliance with evidence based practices.
- Assist providers in developing fidelity self-monitoring processes to enhance consistent fidelity to evidence based practices.
- Research health care and related regulations and conduct ad hoc research to analyze, interpret and disseminate guidance on legal, contractual and regulatory requirements.
- Collaborate with internal and external teams, legal and regulatory resources regarding solutions to address potential legal, contractual and/or regulatory issues.
- Monitor the submission of contract deliverables to state agencies ensuring timely, accurate and appropriate submission of all state filings related to health plan licensure.
- Coordinates responses to state agency inquiries.
- Assist with identifying and resolving inefficiencies, training staff on compliance requirements and controls, and/or the development of an annual audit plan that identifies and prioritizes areas of significant compliance risk.
- Design and implements programs, policies, and practices for full state and federal program contract compliance, as well as compliance with federal and state legal and regulatory requirements.
- Validates state and federal deliverable reports for accuracy and verifies timeliness of submission including ad hoc requests for information, Corrective Action Plan (CAP) submissions and audit information.
- Bachelor’s degree in Nursing or related field. Master’s degree preferred.
- 5+ years of experience in healthcare administration, patient/community advocacy, case management or combined care management and clinical nursing experience.
- 3+ years of auditing or process improvement experience, in a managed care setting preferred.
- Knowledge of Medicaid contract requirements preferred.
License/Certification: AZ Registered Nurse licensure