RN Compliance Team Lead (Hybrid / Remote) - Program Optimization - 40 Hours Weekly - Day Shift - HAP Health Alliance Plan

RN COMPLIANCE TEAM LEAD (HYBRID) - PROGRAM OPTIMIZATION - 40 HOURS - DAY SHIFT - HAP HEALTH ALLIANCE PLAN

Full Time Benefit Eligible

Schedule: Monday through Friday, Five 8-hour shifts per week with start times flexible between 7:30 AM and 9:00 AM

GENERAL SUMMARY:

Unit Description: 

Health Alliance Plan (HAP) is looking to add to our clinical Training & Compliance team with an experienced Registered Nurse! In this role, you are responsible for Health Care Management division training, as well as regulatory monitoring and oversight of Utilization Management, Appeals & Grievance, and Care Management departments.

Our department consists of a blend of seasoned clinical and non-clinical professionals. We have a great team always willing to lean in and help each other. The ideal candidate has a minimum of three years of clinical and/or systems training experience, is team-oriented, is successful working independently, takes initiative and demonstrates leadership qualities, and thrives in a setting that is continuously evolving. Though we primarily work remote, at times we travel to our Troy Corporate Headquarters for in-person meetings, training, and support of CMS or NCQA audits.  Interested in learning more? Apply now!

• Lead the daily compliance and training activities of the unit, including providing assistance for the division, supporting unit goals and objectives, monitoring quality and unit processing, assisting with implementation of procedures and processes, maintaining continual oversight of all activities impacting compliance, and acting as a clinical resource for the unit by providing direction for improvements. 

• Provide communication to management team to keep them abreast of compliance and training issues, and concerns within the unit.

• Work with department management, clinical staff, HAP providers and managed care community to ensure all division activities adhere to CMS, State of Michigan and NCQA guidelines where applicable.

• Identify trends and patterns of non-compliance which have potential for quality of care or fiscal impact and recommend areas for intervention and improvement.

• Participate in planning and conducting compliance oversight studies including data collection, analysis, and follow-up activities.

• Collaborate with compliance staff members, department leaders, medical directors, vendor management, information technology, and corporate compliance to ensure compliance across all HCM departments and with all associated delegates and first tier, downstream and related entities (FDR’s).

• Lead, plan, develop, and conduct education and training activities for HCM new hires, vendors documenting in HCM systems, new process implementation, and remedial/refresher education related to operations or compliance.

• Develop and/or revise policies, procedures, documents, forms, tools, job aids, training, and awareness materials for HCM division in accordance with Government programs regulations, obtaining corporate approvals as necessary.

• Serve as compliance and training subject matter expert for a variety of HCM initiatives (e.g., product development efforts, new sales channel implementations, provider initiatives, information technology advancements, etc.) and ensure these key HCM initiatives are taken from development to fruition in a compliant manner including recommending enhancements.

• Develop presentations for departments and individuals at all levels to provide training and compliance updates.

• Assess and communicate professional developmental needs and other resource needs to optimize efficiency and enhance departmental team activity.

• Monitor staff assignments to ensure appropriate compliance oversight of all applicable activities.

• Complete investigations and inquiries as needed.

This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and duties. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described above.