Director, Operations Quality Assurance
: Job Details :

The Director Operations Quality Assurance leads an operational audit team which works with business partners to audit compliance related and business health indicators, identify errors for both areas, and ultimately partner with business leaders to identify, implement and monitor technology and data-driven solutions. The incumbent contributes to our business growth and effectiveness by leading operational audit teams' performance, procedures, and reporting and continually strategizing how best to measure adherence to operational standards. He/she ensures Healthfirst remains regulatory compliant by understanding, interpreting, and ensuring the timely implementation of all new and revised reporting requirements by Centers for Medicare & Medicaid Services (CMS) and New York State (NYS) Regulatory agencies. The incumbent partners closely with regulatory, compliance, operations (i.e., Contact Center Operations, Enrollment and Billing, Claims Operations, etc.), claims audit business analytics, and IT to ensure the collective is working in concert in support of regulatory adherence.Duties/Responsibilities:Design and execute the operations internal audit strategy to assess financial, operational, and compliance risksLead a team responsible for performing a variety of operational audit functions across business teams, including identifying new and innovative methodologiesDevelop talent to meet departmental objectivesConduct regular audits on various operations departments and processes to ensure compliance with regulatory standards and internal policiesLead, coordinate, and actively participate in managing audit planning, conducting audits, preparing audit evidence, assessing the quality of audit evidence, and ensuring audit readiness for Operations auditsContribute to executing onsite and/or desk audits and collecting anticipated audit findingsIdentify control weaknesses, potential risks, and opportunities for process improvementWork closely with external auditors and regulatory bodies, ensuring alignment in audit findings and follow-up actionsDevelop and implement quality assurance frameworks and standards across various operationsOversee quality assessments to ensure that customer service, claims processing, and other critical functions meet defined quality benchmarksInstitute reporting and analytics capabilities that provide insights and trends, performance improvement recommendations, sound statistical sampling and audit source dataHelp evaluate technology solutions to identify solutions offering workflow improvement, reporting, analytics, and AIAssist in identifying and implementing robust automated systems to obtain, aggregate and house results with real-time and on-demand reportingAnalyze data from quality assessments to identify trends, areas of improvement, and training needsWork with departments to establish performance metrics and monitor adherence to quality standardsEnsure compliance with healthcare regulations and industry standards, addressing changes in regulatory requirementsRecommend process improvements to enhance operational efficiency and reduce errors or compliance issuesKeep abreast of industry issues and trends to proactively shape Internal Audit, Quality Assurance and Testing practices and proceduresCollaborate with external vendors, ensuring SLAs are met along with all contractual obligationsAdditional duties as assignedMinimum Qualifications:Bachelor's degree from an accredited institution or relevant experienceWork experience requiring knowledge of an array of NYS and federal rules and guidelines that impact Contact Center Operations, Enrollment and Billing and Claims operations for Medicaid, Medicare, and Commercial lines of business (i.e. contract laws, prompt pay, etc.)Work experience requiring knowledge of Medicaid and MedicarePrevious management and oversight experience of regulatory and compliance initiativesPreferred Qualifications:Substantial experience leading complex, operations-wide initiatives and the development and implementation of impactful audits and root cause analysesScience and research-based knowledge in a variety of topics related to operational auditsStrong facilitation, consulting, and influence skills across a variety of audiencesExceptional verbal and written communications and content: concise, clear, simple, visually appealingProven ability to manage and collaborate with senior stakeholders and across operations teamsProject management experiencePower BI Microsoft software toolCompliance & Regulatory Responsibilities: Noted aboveHiring Range*:Greater New York City Area (NY, NJ, CT residents): $150,800 - $230,690All Other Locations (within approved locations): $124,400 - $190,315As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.#J-18808-Ljbffr