The Regulatory Specialist, SLA, is responsible for performing different tasks to ensure service level agreements and accreditation standards are complete.
Essential Duties and Responsibilities:
Collaborate with Quality Accreditation and Regulations team and leadership to assist in identifying quality issues and root causes and help to coordinate intervention plans
Partner with the quality team, network management, case management, member services, providers, etc., as well as external, (i.e., provider/designated group contacts) in the evaluation, communication, outreach, and support of non-compliant members, providers, and groups
Provide education and training for staff
Compile various internal and external reports; obtain approval and distribute as necessary
Collect documents and reports from internal and external stakeholders
Ensure that reports are analyzed and reported by responsible entities in a timely manner and in accordance with the NCQA activities calendar
Partner, collaborate, develop, and support Regulatory Specialists within the Clinical Operations-Quality, Audit, and Risk department as follows:
Care management and regulatory initiatives
Create and maintain audit tools, reports, standardized policies, procedures, and manuals
Assess survey readiness for NCQA accreditation and state and federal-based quality improvement compliance
QI compliance-related activities are accomplished each year
Direct compliance issues to appropriate channels for investigation and resolution
Write, review, develop, revise, and maintain policies and procedures for the general operation of the Somatus compliance program and its related non-compliant activities ensuring they are in line with standards for accreditation, agency contract needs, and ongoing continuous quality improvement
Acquire a thorough knowledge of each program and/or department operations and procedures
Collect, compile, trend, and report quality data in the following areas: patient care, safety, risk management, infection control, outcomes, and customer satisfaction
Investigate, manage, and analyze variances, incidents, and risk management data
Comply with risk management-related standards for CMS, NCQA, and other accrediting agencies
Complete credentialing packages and applications for new and current providers
Resolve any issues related to provider credentialing
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Required Education and Experience:
Bachelor's degree in Nursing or other related fields
Two (2) years of experience with NCQA
Strong clinical background
Knowledge, Skills, and Abilities:
Possess an intermediate level of knowledge of local, state, and federal laws and regulations on guidelines of provider and/or healthcare care management
Ability to document and analyze complex business requirements and processes
Strong analytical skills
Ability to be both a strategic and tactical change agent in the healthcare space
Self-starter who will take initiative and be proactive when there are multiple priorities
Strategic solution-seeker who sees opportunities when others see barriers
Strong interpersonal skills and ability to communicate effectively
Ability to handle ambiguity and desire to work in a fast-paced start-up environment
Detail-oriented, accurate and complete work timely
Ability to communicate in a courteous and professional manner with teammates, leadership, vendors, and others
Proficient in MS Office
This position may require up to 10 - 25% travel. Travel may be outside the local area and overnight.
This job operates in a professional setting. While performing the duties of this job, the employee is regularly required to sit or stand for extended periods of time. Normal manual dexterity is required.
Normal speaking and hearing abilities to interact with others in an office environment, over telephone or other video conferencing platform.
The employee is occasionally required to stand; walk; and reach with hands and arms and continuously repeat the same hand, arm finger motion many times as in typing.
Our priority is the health and safety of our members, colleagues, partners, and community. Proof of COVID-19 Vaccination is required for employment. If you are unable to be vaccinated for medical reasons or sincerely held religious beliefs, we will consider requests for reasonable accommodations consistent with our policy, and where we are able to provide such accommodations without undue hardship to the company pursuant to applicable law.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Somatus, Inc. provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law. Further, the company takes affirmative action to ensure that applicants are employed, and employees are treated during employment without regard to any of these characteristics. Discrimination of any type will not be tolerated.