Compliance & Accreditation Specialist Job Listing at Medical Mutual in OH (Job ID 2400422)

Description

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.

Under general supervision, collaborates to assure the Company is compliant with assigned National Committee of Quality Assurance (NCQA) accreditation requirements, Quality Programs, and regulations such as Medicare Advantage, Medicaid, and Marketplace Exchange, and Office of Personnel Management quality requirements for FEHB. Works across departments and divisions on various projects designed to reduce the risk of non-compliance, save costs, improve operational efficiency and quality, and enhance customer satisfaction while meeting best practices and business performance goals.

This position has the option to work hybrid or fully remote; Ohio residents preferred. 

Responsibilities

Compliance & Accreditation Specialist

• Interprets standards and regulations and advises management on the policies, procedures, reports, materials, and files required to meet scoring standards. Supports policy development and review.  Regularly audits documents, materials, and file samples to gauge the level of compliance. Resolves any areas of non-compliance in collaboration with the Director. Collaborates with functional departments on solutions that meet best practices and to assure consistency related requirements. Updates annual training materials with new standards/elements/factors.
• As assigned, acts as supporting liaison between credentialing, network management and Quality to ensure committee requirements, regulatory oversight and review of medical staff credentials are coordinated and in sync.
• Manages external vendor relationships to assure delegated entities meet requirements. Conducts quarterly and annual audits of documents, materials, and file samples to gauge the level of compliance. Writes analyses. Resolves any areas of non-compliance including developing and monitoring corrective action plans.
• Supports NCQA applications, submissions, and onsite surveys for the Commercial, Exchange, Medicare/Medicaid Products.  Collaborates with Legal on assuring the accurate completion of contracts.  Supports the relationship with NCQA to assure the Company is put forth at a high standard. 
• Supports the NCQA accreditation survey application and review process, including collecting, preparing, and submitting documents and files timely; arranging onsite logistics; serving as liaison with audit team; collecting and preparing responses to auditors; and ensuring appropriate information is communicated to leadership and enterprise wide.
• As assigned, in the absence of a state or regulatory body survey, conducts site visit surveys to verify State and/or CMS survey certificates for any current sanctions, restrictions on licensure and/or limitations on the scope of practice on all credentialed providers in interim credentialing periods.
• Analyzes data from various systems, member and provider surveys and ad hoc financial reports. Writes reports to meet regulatory requirements. May conduct observational studies of staff workflows.  Detects patterns, trends, and variations; composes detailed reports, and presents findings and recommendations to management and/or to committee participants.
• As assigned, works with credentialing and provider relations staff regarding data integrity of credentialing database, generates reports and reconciles discrepancies.
• Stays current on applicable accreditation and government- related compliance standards and regulations and communicates changes.
• Performs other duties as assigned.

Senior Compliance & Accreditation Specialist

• Interprets standards and regulations and advises management on the policies, procedures, reports, materials, and files required to meet scoring standards. Supports policy development and review.  Regularly audits documents, materials, and file samples to gauge the level of compliance. Resolves any areas of non-compliance in collaboration with the Director. Collaborates with functional departments on solutions that meet best practices and to assure consistency related requirements. Updates annual training materials with new standards/elements/factors. Trains college associates, peers, and emerging leaders on important aspects of accreditation and clinical compliance.
• As assigned, acts as the supporting liaison between credentialing, network management and Quality to ensure committee requirements, regulatory oversight and review of medical staff credentials are coordinated and in sync.
• Manages external vendor relationships to assure delegated entities meet requirements. Conducts quarterly and annual audits of documents, materials, and file samples to gauge the level of compliance. Writes analyses. Resolves any areas of non-compliance including developing and monitoring corrective action plans.
• Supports NCQA applications, submissions, and onsite surveys for the Commercial, Exchange, Medicare/Medicaid Products. Collaborates with Legal on assuring the accurate completion of contracts.  Supports the relationship with NCQA to assure the Company is put forth at a high standard. 
• Manage NCQA accreditation surveys, including collecting, preparing, and submitting documents and files timely; arranging onsite logistics; serving as liaison with audit team; collecting and preparing responses to auditors; and ensuring appropriate information is communicated to leadership and enterprise wide.
• As assigned, in the absence of a state or regulatory body survey, conducts site visit surveys to verify State and/or CMS survey certificates for any current sanctions, restrictions on licensure and/or limitations on the scope of practice on all credentialed providers in interim credentialing periods.
• Analyzes data from various systems, member and provider surveys and ad hoc financial reports. Writes reports to meet regulatory requirements. May conduct observational studies of staff workflows.  Detects patterns, trends, and variations; composes detailed reports, and presents findings and recommendations to management and/or to committee participants.
• As assigned, works with credentialing and provider relations staff regarding data integrity of credentialing database, generates reports and reconciles discrepancies.
• Stays current on applicable accreditation and government- related compliance standards and regulations and communicates changes.  Mentors more junior specialists through training, ongoing coaching, and partnering in Accreditation and Compliance efforts.
• Performs other duties as assigned.

Qualifications

Compliance & Accreditation Specialist

Education and Experience

• Bachelor's degree in nursing, health sciences, or related field.
• Master's degree preferred.
• 3 years of experience in accreditation, compliance, or quality, preferably in a health plan or healthcare.

Professional Certification(s)

• Certification in quality or related field by a nationally recognized professional association is desired.
• Registered Nurse with current State of Ohio unrestricted license preferred.

Technical Skills and Knowledge

• Knowledge of medical terminology, NCQA accreditation standards and applicable government regulations such as Medicare, Medicaid, and the ability to apply advanced concepts to business operations.
• Knowledge and evidence of data analysis and report writing.
• Intermediate  computer skills including Access, Excel, Word and PowerPoint.
• Strong analytical and process improvement skills.
• Strong written and verbal communication skills with a demonstrated command of grammar, spelling and sentence structure.

Senior Compliance & Accreditation Specialist

Education and Experience

• Bachelor's degree in nursing, health sciences, or related field.
• Master's degree preferred.
• 5 years progressive experience as a Health Plan Compliance & Accreditation Specialist or equivalent experience in  accreditation, compliance or quality, preferably in a health plan or health care.
• Previous project management experience is preferred.

Professional Certification(s)

• Certification in quality or related field by a nationally recognized professional association is desired.
• Registered Nurse with current State of Ohio unrestricted license preferred.

Technical Skills and Knowledge

• Strong knowledge of medical terminology, NCQA accreditation standards and applicable government regulations such as Medicare, Medicaid, and the ability to apply advanced concepts to business operations.
• Strong knowledge and evidence of data analysis and report writing.
• Intermediate to advanced computer skills including Access, Excel, Word and PowerPoint.
• Strong analytical and process improvement skills.
• Strong written and verbal communication skills with a demonstrated command of grammar, spelling and sentence structure.

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.

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