COVID-19 VACCINATION REQUIRED FOR ALL YCCO EMPLOYEES EXCEPT FOR AN APPROVED ACCOMMODATION FOR MEDICAL OR SINCERELY HELD RELIGIOUS BELIEF. PLEASE SEE ADDITIONAL INFORMATION BELOW.

Department:    QUALITY ASSURANCE & COMPLIANCE                             FLSA Status:            EXEMPT

Reports To:      QUALITY ASSURANCE & COMPLIANCE DIRECTOR              Physical Strength:    LIGHT (L)

SUMMARY

This position is responsible for monitoring the performance of managed care subcontractors on an ongoing basis and conduct formal reviews of those entities’ compliance with delegated responsibilities and their performance, deficiencies, or areas for improvement in accordance with Oregon Health Authority (OHA) contracts by performing the following duties.

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ESSENTIAL DUTIES

1. Perform internal and subcontractor auditing functions and follow-up.
2. Participate in External Quality Review (EQR) activities, including preparation, submission, and improvement planning/corrective action. 
3. Provide technical assistance and training to subcontractors on compliance-related issues.

JOB DUTIES

Subcontractor Compliance

• Conducts pre-delegation and annual audits for new and existing delegated entities for compliance in the following areas: Utilization Management, Authorization, Clinical Guidelines, Appeals, and Managed Physical, Behavioral and Dental Health Operations.
• Ensures delegation expectations and standards are clearly understood by subcontractors.
• Meets with and remains in contact with subcontractors to ensure delegation expectations and standards are clearly understood.
• Monitors and evaluates subcontractors to ensure performance of delegated activities in accordance with the agreement and regulatory requirements.
• Works in coordination with the Quality Assurance & Compliance Team, Health Plan Operations Team, and Health Services Team including the Chief Medical Officer (CMO), to monitor and analyze outcomes to ensure goals, objectives, and regulatory requirements are met.
• Provides technical assistance and training to subcontractors, as needed, regarding compliance intervention strategies.

Audit & Compliance

• Works independently to interpret and apply complex regulations, laws, and guidelines and to evaluate delegated entities for compliance with contractual and regulatory requirements.
• Develops, revises, and maintains all audit tools and written agreements as necessary to comply with State and Federal regulatory requirements.
• Maintains all documentation to support evidence of compliance with all delegation requirements.
• Provides technical assistance, as needed, regarding compliance intervention strategies.
• Prepares completed audit reports including correspondence and corrective action plans to ensure that provider satisfies all requirements within allotted timeframes.
• Conducts audits of delegated functions using audit tools and develops corrective action plans to address any identified issues.
• Ensures the subcontractor performs the delegated activities in accordance with the agreement and regulatory requirements.
• Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, EQRO) as requested.
• Administers annual risk assessment process to identify and collect organizational risk and supports the development of the annual audit plan.
• Participates in Yamhill Community Care (YCCO) Compliance Committee meetings.

Policy & Reporting

• Collects and summarizes performance data, identifies opportunities for improvement, and presents findings to the Quality and Clinical Advisory Panel.
• Ensures the development of policies and procedures that comply with state regulations and/or accrediting body requirements as applicable.

ESSENTIAL DEPARTMENT & ORGANIZATIONAL FUNCTIONS

• Participates in the preparation and submission of regulatory and contract required deliverables.
• Works closely with other YCCO departments, including Health Plan Operations and Health Services for auditing purposes, including the External Quality Review (EQR), as needed.
• Proposes and implements process improvements.
• Meets deadlines for completion of workload.
• Maintains agreed upon work schedule.
• Demonstrates cooperation and teamwork.
• Provides cross-training on specific job responsibilities.
• Meets identified business goals that contribute to departmental goals.
• Maintains punctual, regular, and predictable attendance.  
• Works collaboratively in a team environment with a spirit of cooperation.
• Respectfully takes direction from Director.
• Other duties as assigned.

KNOWLEDGE, SKILLS, & ABILITIES

• Understanding of managed care principles for both Medicaid and Medicare.
• Knowledge of network health service delivery systems.
• Ability to identify best practices as they relate to delegated functions.
• Ability to communicate both professionally and effectively verbally and in writing.
• Ability to analyze general, statistical, and technical reports, and synthesize data from diverse sources for writing audit reports.
• Ability to interpret regulatory and contractual obligations required of CCOs.
• Understanding of State and Federally managed care program requirements including Oregon Health Plan (OHP) and Medicare.
• Knowledge of auditing processes.
• Ability to perform independent analysis, critical thinking, and sound clinical judgment.
• Ability to coordinate and communicate with a variety of contract parties and stakeholders.
• Be self-directing with minimal supervision.
• Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a matrix or shared resources across departments work model.
• Possess a high degree of initiative and motivation along with the ability to effectively collaborate and plan with others.
• Excellent organizational skills and ability to manage multiple tasks and timelines simultaneously, as well as to perform work with attention to detail.
• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
• Ability to work in an environment with diverse individuals and groups.
• Ability to work across the YCCO region and to work remotely, as needed.

SUPERVISORY RESPONSIBILITIES

This position has no supervisory responsibilities. 

QUALIFICATIONS

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

EDUCATION & EXPERIENCE

Required:

• Minimum of four (4) years’ experience in compliance and auditing, including regular exposure to quality expectations, policies, and standards.

     OR

• Any combination of education and experience that would qualify the candidate for the position.

Preferred:

• Master’s or Bachelor’s degree in health administration, public health, or health related field,
• Experience with managed care processes, operations, and auditing of clinical programs,
• Experience administering the Oregon Health Plan (OHP) (Medicaid),
• Experience administering the Centers for Medicare and Medicaid Services (CMS) (Medicare) benefits.

CERTIFICATES, LICENSES AND/OR REGISTRATIONS

Preferred:

• Certified Professional Coder.
• Certified Professional Biller.
• Certified Professional Medical Auditor.
• Similar/Equivalent Certification.

PHYSICAL DEMANDS & WORK ENVIRONMENT

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds.

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate.

This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.

ADDITIONAL INFORMATION ABOUT COVID-19 VACCINATION REQUIREMENTS

To safeguard the health of our employees and their families; our members and visitors; and the community at large, YCCO requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious accommodation as a qualification of employment.

Job candidates that receive a contingent offer of employment from YCCO must provide proof of COVID-19 vaccination, along with a completed attestation that the documentation submitted is true and correct to Human Resources Department;

OR

Submit a completed request for accommodation form due to a medical reason or sincerely held religious belief to the Human Resources Department to begin the interactive accommodation process.