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Oversight Compliance Consultant Sr.

Location:

  • Florida, Florida
  • Texas, Texas
  • Indiana, Indiana
  • Virginia, Virginia
  • Georgia, Georgia
  • California, California

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Description

Title : Oversight Compliance Consultant Sr.

Location : Requires office time anywhere from 1 - 3 days a month, the remainder is remote.

Hours : Standard

Build the possibilities. Make an extraordinary impact:

Responsible for serving as point of contact, coordinating and collaborating primarily with delegated entities and internal health plan functional units to ensure compliance with regulatory, accrediting and health plan quality of care and service requirements. Promotes and maintains favorable working partnerships and relationships with delegated entities, physicians, healthcare service providers, and internal customers to improve delivery and quality of health care.

How you will make an impact:

  • Performs annual and ad hoc delegation oversight audits and internal health plan functional unit audits.
  • Develops corrective action plans and analyses of required program reports and internal performance measures.
  • Acts as an operational expert and interventionist through communication, education, and design of programs and strategies to assist delegated entities and internal departments meet regulatory and accrediting standards, promote quality outcomes, and maximize resources.
  • Develops training materials and conducts training and/or new hire orientation.
  • Delivers timely and constructive coaching and feedback.
  • Assists with planning and implementation of formal education sessions to external customers to address non-compliance issues.
  • Takes lead with healthcare industry collaborations so as to enhance regulatory and accrediting compliance among constituents.
  • Ensures that all policies and procedures are updated as legislation or accreditation standards change.
  • Assists with standardization of procedures and documentation.
  • Assists in problem-solving with delegated entities and internal constituents. 

Minimum Requirements:

  • Requires AS in nursing and minimum of 5 years of acute care, utilization management, quality management in a hospital and/or HM setting and minimum of 2 years of experience conducting oversight audits of delegated entities and/or ancillary providers; or any combination of education and experience, which would provide an equivalent background.
  • Current unrestricted RN license or LCSW in applicable state(s) required.
  • Strong knowledge of managed care principles and delivery systems, the medical management process, accreditation and regulatory standards, delegated oversight processes, and workflow systems strongly preferred.
  • BS in nursing preferred.
  • Travel may be required.

Preferred Skills, Capabilities and Experience:

  • Knowledge of clinical medical, behavioral, and pharmacy claims regulatory requirements such as experience with CMS compliance, and state regulatory and accreditation requirements preferred.
  • Medicare Managed Care, Medicaid, and Commercial utilization management processing experience related to delegation oversight and auditing, reporting-Part C, monthly timeliness, etc. is preferred.

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance.

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