Sr Clinical Operations Compliance Specialist-MA

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Acts as a subject matter expert and collaborates with various internal departments to ensure that Medicare Advantage (MA) clinical programs and regulatory reporting are compliant with CMS guidance, improve quality and operational efficiency, and enhance overall satisfaction for MA members. Develops and maintains policies and procedures and Corrective Action Plans (CAP) to align with CMS guidance and to address deficiencies or issues identified in the internal monitoring process. Manages external vendor (FDR) oversight to assure delegated entities maintain compliance with contracts and applicable CMS guidance.

Responsibilities:

* Maintains knowledge of and interprets CMS managed care guidance and develops and maintains policies, procedures, learning materials, documentation and SharePoint sites to maintain MA clinical compliance. Monitors internal and delegated requirements (e.g. ODAG and Part C universes) for compliance with CMS reporting specifications. Resolves areas of non-compliance including development and monitoring CAP in response to issues or deficiencies identified during internal monitoring. Reports findings to management and MA Compliance via presentations and Dashboard. Ensures audit ready preparedness for both annual and ad-hoc audits with CMS. Collaborates across departments to assure consistency with CMS guidance, applicable Stars measures and other related requirements. Informs MA staff of updates to CMS guidance and related policies and procedures.

* Manages the oversight of designated FDRs regarding delegated responsibilities per signed contracts. Monitors FDR processes for compliance with contract and any applicable CMS guidance. Resolves any areas of non-compliance including development and monitoring of CAPs with FDRs. Reports findings to CQHS management and MA Compliance via presentations and Dashboard. Informs FDRs of updates to CMS guidance and related processes and procedures.

* Collaborates with CQHS management and Clinical Learning & Development in identifying training needs and in the development and maintenance of MA learning materials and process workflows.

* Works across departments and division on various projects and committees to reduce the risk of non-compliance, improve operational efficiency, improve quality, and enhance MA member satisfaction. Represents Clinical Operations in audits and committees and in MA Compliance activities.

* Performs other duties as assigned.

Qualifications

Education and Experience:

* Graduate of a registered nursing program approved by the Ohio State Nursing Board.

* Bachelor's Degree in nursing, business, health sciences, or related field required.

* 5 years progressive experience in health plan clinical operations which includes work in government programs (Medicare) compliance, regulatory audits and process improvement.

Professional Certification(s):

* Registered Nurse with current State of Ohio unrestricted license.

* Process Improvement certification preferred (e.g. Six Sigma).

* Legal Nurse Consultant certification preferred.

Technical Skills and Knowledge:

* Strong knowledge of clinical operations compliance and the ability to develop policies, procedures and process workflows.

* Strong knowledge of CMS managed care guidance, legal definitions and other Medicare requirements.

* Strong continuous process improvement skills which includes root cause analysis, risk identification and corrective action planning.

* Knowledge of fundamentals of training including adult learning principles.

* Strong verbal and written communication skills including the ability to make presentations.

* Intermediate to advanced Microsoft Office skills.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits and Compensation:

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance - insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year, the IRS maximum.
• Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:

Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.

At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.