Blue Cross Blue Shield of Massachusetts

Ready to help us transform healthcare? Bring your true colors to blue. 

What we need:

As an integral part of HMM Quality and Compliance team, the Senior Medicare Clinical Compliance Consultant works through the influence as an individual contributor while collaborating and providing guidance to HMM teams, company leaders within and outside of HMM to achieve compliant processes.

This position leverages analytical, leadership and organizational skills to perform audits, summarize and communicate findings to various levels in the organization, perform gap analysis, risk assessment, track issues/ risks to closure, and collaboratively develop mitigation strategies. 

Your Day to Day:

• With minimal oversight, leads CMS utilization management related compliance activities including:
• Identify and implement new CMS requirements
• Monitor, audit, gap identification, analysis, and summarize key findings to various levels in the organization
• Accurately calculate and identify risks, formulate recommendations, and escalate to senior leaders for decision making
• Apply their clinical knowledge when assessing/auditing medical records and UM letters against medical necessity criteria and accreditation and regulatory criteria
• Review applicable policies and procedures to ensure all are up to date and reflect the appropriate compliance with regulatory and compliance requirements
• Ensures required CMS Part C organization determination reporting is accurate
• Accurately plan and scope projects; keep project leads, senior consultants, and Director informed of key issues/ risks and meet deadlines by tightly managing deliverables, coordinating input from leaders, and ensuring all tasks are performed to bring projects to a timely closure.
• Build trusting and credible relationships to engage stakeholders and be responsible for driving improvement
• The ability to matrix and leverage relationships within HMM and with outside business partners regarding advancing quality improvement goals, corrective action plans, and meeting CMS expectations for a compliance effectiveness program
• Provide mentoring/ coaching/ direction to Q&C team members as needed; share expertise with all HMM associates through educational opportunities, and job shadowing
• Lead or represents department on cross functional workgroups and projects as a subject matter expert (SME)
• Collaborate with Director and Senior Program Consultants to identify/ implement workflows and process improvements to maximize quality, efficiency, and cost effectiveness of team

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.

We’re Looking for:

• Strong clinical skills and understanding of CMS Part C guidance including UM operational procedures, and CMS guidance including coverage and benefit conditions included in Medicare laws, National Coverage Decisions (NCDs) and Local Coverage Decisions (LCDs)
• Strong critical thinking, research, planning, organization, and time management skills including the ability to meet deadlines, problem solve, manage multiple competing priorities, and achieve goals
• Decision quality: makes good decisions based on analysis, wisdom, experience, and judgement. Can explain rationale, solutions and suggestions are accurate over time, and is sought out by others for advice and solutions
• Demonstrated leadership skills including strong interpersonal, relationship building, consensus building, process management, negotiating, influencing, the ability to manage change, and provide constructive feedback
• Strong written communication, meeting facilitation, and presentation skills; can independently write gap analysis and root cause analysis from brainstorming sessions
• Strong computer and analytical skills: ability to navigate, interpret/ draw conclusions, identify gaps/ issues & analyze information from the utilization management medical management system: Care Prominence (i.e. MHK), Word, Excel, Adobe Acrobat, PowerPoint, and MS Outlook
• Knowledge of compliance and QI techniques and theory

What You Bring:

• Active and Unrestricted Massachusetts Registered Nurse license required
• Bachelor's degree in healthcare or related field
• 3-5 years’ experience working with CMS Part C utilization management organization determination compliance and reporting or other regulatory/ accreditation third party audits
• Experience auditing, monitoring, risk assessment, gap analysis, and closing out corrective action plans timely
• 5 years’ experience in a health plan and/or clinical experience within a managed care organization
• 3 years of managing people, projects, or relevant consulting experience; this may include providing guidance, instruction, training, analyzing complex problems and providing leadership.

What You’ll Gain:

• Meaningful work that is important to the company
• Being part of a high performing team
• Opportunity to collaborate with leaders and associates across the organization 

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Hingham

Time Type

Full time

: $ - $

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay “in the know” on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.