AmeriHealth Caritas Medicare QA Specialist in Charleston, South Carolina
Medicare QA Specialist
Location: Charleston, SC
Primary Job Function: Medicare
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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .
The Medicare Quality Assurance Specialist serves as a subject matter expert within the Company regarding Medicare rules and works with individual departments to research, identify and address areas of vulnerability related to regulatory compliance in order to create subsequent tracking and monitoring tools to ensure quality assurance across all Medicare lines of business. This includes but is not limited to responding to internal requests for regulatory interpretation and guidance; tracking, reviewing and analyzing policies, contract requirements, model of care requirements, and state and federal rules and regulations and compliance requirements that could impact Medicare lines of business and ensuring that the proper monitoring tools are in place. The Medicare Quality Assurance Specialist works closely with the Medicare Quality Assurance/Operations Control Analyst to create the necessary monitoring tools for quality assurance based on feedback and analysis.
Assist the Medicare Contract Account Manager in validation and education of the business regarding HPMS memo interpretation, and ensure the business completes proper HPMS guidance implementation (ex. assist business owners with drafting of policies in order to effectuate CMS guidance/rules/HPMS memos, DHHS guidance etc.).
Read, interpret, summarize, and assess the impact on business operations based on Medicare/state regulations, guidance, and communications.
Assist business owners with the drafting of policies, desktop procedures, and corrective action plan responses as needed.
Support the Compliance team in the administration of internal and external audits including but not limited to data validation audits.
Monitor and validate for compliance all Medicare products including but not limited to the provider directory, formulary, marketing materials, and plan websites. Ensure that the Centers for Medicare & Medicaid Services (CMS) Audit Protocols are implemented in the quality assurance monitoring tools and oversight.
Provide training and presentations to internal departments as needed.
Document and maintain project plans and status reports as related to quality assurance, oversight, monitoring, audits, and other ad hoc initiatives as needed.
Coordinate the oversight of PerformRx and subcontracted vendors to ensure compliance with Medicare requirements.
Support the transmittal of information and documentation as needed during audits and other ad hoc initiatives.
Acts as the regulatory lead on new and continuing implementation activities.
Provide contract administration support.
Education and Experience:
Bachelor's Degree or Equivalent Experience Required.
3 - 5 years of Professional work experience in regulatory, privacy, and/or legislative policy and processes, preferably in a managed health care setting.
1-3 years of Managed Care including Star Ratings.
Must possess strong research and analytical skills, as well as excellent written & oral communications skills
Demonstrated competency in research and tracking of health policy and regulations.
Possesses ability to analyze and interpret policy, ability to identify relevance and potential to Medicare Advantage.
Proficiency with MS Office Suite and Internet required
EOE Minorities/Females/Protected Veterans/Disabled