Regulatory Performance Analyst

US-Irvine, CA or Chicago, IL
Req No.
2017-2178
Category
Operations
Type
Regular Full-Time

Overview

ConcertoHealth Inc. is the leading provider of specialized primary care and supporting clinical services for complex, frail, elderly, and dual-eligible patients. Operating exclusively in value-based agreements, ConcertoHealth provides high-touch, individualized care for patients, and deploys wraparound clinical resources to extend the reach of primary care practices. This comprehensive medical management solution, elevated by Concerto’s proprietary population health technology, improves overall healthcare quality and patient outcomes, benefitting payers and their provider networks. The company is headquartered in Irvine, Ca. For more information, please visit www.concertohealth.com.
 
The Regulatory Performance Analyst will monitor compliance of all contractual and regulatory obligations to the Company’s health plan and provider partners. The role will make recommendations on development and operational management processes, validate operational execution through reporting, and oversee and manage key projects. 

Responsibilities

  • Monitors the Company’s internal operations to ensure compliance with regulatory and contractual obligations, defines and produces reporting to escalate risks and makes recommendations which will improve operational execution against requirements.
  • Participate in the definition and development of operational dashboards or scorecards to monitor compliance with contract requirements & support the development of improvement strategies, as needed.
  • Maintains working knowledge of basic healthcare regulatory requirements (e.g. CMS, Duals Demonstrations, Medicaid, NCQA, quality/Stars, etc.)
  • Supports implementation activities by defining business requirements for internal business owners that will comply with regulatory and contractual obligations.
  • Collaborates with clinical operations, utilization management, and other functional departments to support regulatory or contractual obligations. Interfaces, when appropriate, with all areas affected by the project to include internal subject matter experts and external clients, including vendors.
  • Develop and maintain positive relationships with key health plan operations.
  • Development of operational reporting, including building or refining reporting business rules as needed, and validation of regulatory reports for our delegated arrangements.
  • Provide support for regulatory or contractual submissions, such as Organizational Determination reports (ODAG) reporting. Ensure reporting is submitted to plan partners timely.
  • Develop/maintain operational monitoring tools, including Regulatory Reporting Grid and Health Plan Reporting Calendar
  • Act as operational lead for regulatory audits, including health plan, CMS, or state audits. Implement audit improvement activities, as identified.
  • Prepare internal reports and presentations in support of Joint Operation Committee meetings and other related meetings
  • Other duties as assigned

Qualifications

  • Minimum bachelor's degree (B.A., B.S., or BSN) from a four-year college or university. Preference for degree in a healthcare related field. 
  • Prior experience in clinical operations and development. Experience in an HMO/IPA/Managed Care setting preferred.
  • Knowledge of clinical standards of care, NCQA requirements, CMS guidelines, and Medicaid/Medicare contracts
  • Demonstrated success serving business clients, and experience in developing and implementing change initiatives
  • Demonstrated experience serving in both strategic and operational roles
  • Ability to work in a Windows based computing environment
  • Strong interpersonal and communication skills, both verbal and written
  • Strong organization skills
  • Goal-oriented, must be able to meet deadlines
  • Ability to maintain professional and positive behavior

Competencies:

  • Analysis/Assessment - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Researches and finds relevant information and identifies key issues and relationships from a base of information; compiling data from a variety of sources and identifying cause-and-effect relationships; Demonstrates attention to detail
  • Attention to Detail - Performs tasks while focusing on all aspects of the task no matter how small; Checks all processes and tasks for accuracy; demonstrates vigilance in assuring completeness and accuracy of all work.
  • Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in-group problem solving situations; Uses reason even when dealing with emotional topics.
  • Project Management - Develops project plans; Coordinates projects; Communicates changes and progress; Completes projects on time and budget; Manages project team activities.
  • Communication - Written, verbal or non-verbal means of expressing ideas effectively including adjusting language, terminology or the organization of concepts to the characteristics and needs of the audience.

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