Lead Analyst (Vendor & Quality Compliance)
To plan, direct, evaluate and coordinate the activities managed within the Internal Quality Auditing department of Consumer Operations, as it relates to quality initiatives, business compliance monitoring, vendor monitoring and internal and external reporting. To perform internal process and system control testing, auditing/monitoring (real-time and retrospective) of all vendor activities supporting the Consumer Operations division. . To .
Principal Duties and Responsibilities:
- Provide daily direction, monitoring and oversight for the Quality Audit process across Consumer Operations, which includes the appropriate coaching and development, planning, staffing and coordination of activities as they pertain to divisional and corporate goals, strategies and objectives.
- Develop a comprehensive monthly monitoring program after identifying audit objectives, reviewing department's policy and procedure, flowcharting and initial evaluation of systems and controls.
- Manage the processes of vendor sourcing, contract execution, budget planning, and vendor performance management. Establish standards and manage the process for vendor contract review and ongoing cost management. Assist in any changes or amendments to the original agreement; evaluates implications on current processes and lead the communication and implementation of changes as needed.
- Develop and communicate a vendor roadmap, governance, strategy and metrics; present recommendations and results to help decisions makers understand the drivers of performance. Participate in end-to-end vendor procurement to ensure vendor management service level agreements are included in the RFI/RFP to final contracting process.
- Audit vendor performance results and share vendor report card with appropriate management. Hold regularly scheduled calls with vendor to discuss Service Level Agreement and dashboard/report card results. Work with vendor to set goals and review during regular scheduled calls, agree to action plans and manage vendor to deliver agreed upon items. As issues are identified, work with vendor to identify root cause and corrective action plans to avoid a reoccurrence of the issue.
- Perform regular end to end monitoring of compliance related processes to ensure that CMS Compliance is consistently being met. Monitor activities involving effective implementation of corrective action plan.
- Develop and implement an on-going training plan for all resources handling inquiries and ensure staff is aware of changing regulatory requirements. Provide just-in-time training to staff based on real-time monitoring results
- Develop and review department and corporate operational policies and procedures in accordance with DIFS, NCQA, DOL and CMS regulations and within departmental standards. Lead team to ensure workflow is continuous, performance standards are met and staff operates within the regulatory mandates such as CMS, NCQA, DIFS, DOL and HIPAA with respect to the various product lines.
- Prepare all data for regulatory agency reviews (NCQA, CMS, DIFS and Medicare 5 Star). Attend regulatory agency interview/audit meetings to answer questions and explain monitoring processes to the various interviewers from these agencies.
- Participate in Medicare Programs workgroups to ensure successful achievement of corporate objectives and regulatory compliance. Participate in Medicare Program conference calls with CMS to ensure changes are understood and communicated effectively to appropriate staff.
- Analyze call center data to identify impacting trends, perform root cause analyst and recommend customer service and process improvements.
- Create and publish detailed reporting metrics for Leadership. Identify areas that require process improvement or staff training.
- Work closely with HAP's Compliance Department to ensure adequate controls are in place.
- Develop skills and competencies of indirect reports to maximize employee engagement, increase productivity and create an environment of teamwork and commitment; coach and counsel people to exceed. performance levels through professionalism, positive relations and timeliness in all customer contacts.
- Perform other related duties as assigned.
- Bachelor's or Master's Degree in Health Care, Business or related field, preferred
- Minimum two (2) years of auditing experience; vendor management/monitoring experience preferred.
- Minimum of four (4) years combined customer service and professional experience in health care, call center, business and/or insurance environment or capacity
- Minimum of two (2) years of project coordination or project management and data analysis, validation and reporting
- Demonstrated knowledge of CMS regulations and guidelines for Medicare products
- Development of project status reports, workplans, timelines, budget reports, risk management, issue lists, and project metrics
- Demonstrated experience with operational data interpretation, analysis, and reporting
- Knowledge of key performance indicators related to health plan or health system performance (i.e. quality, cost/profitability, etc.)
- Analytical experience in a health system or managed care/insurance related setting with specific exposure to member complaints data
- Experience in providing written and verbal communications, including public presentations, to senior leadership
- Certified in Health Care Compliance
- Experience in consulting, market research/quantitative analysis, or healthcare administration working with and demonstrated knowledge of common industry reporting tools
Equal Employment Opportunity/Affirmative Action Employer
Henry Ford Health System is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.