Senior Manager, Program Integrity (Remote)

RISK MITIGATION AND NCQA BRAND PROTECTION THROUGH INVESTIGATIONS:

• Oversee and manage the day to day investigative activities related to recognition and accreditation products regarding complaints, fraud, regulatory sanctions and allegations of other misconduct involving organizations or clinicians with current NCQA Accreditation, Certification, or Recognition status.

DRIVE CONSISTENCY AND QUALITY

Participate in Survey Reconsideration and Audit processes, including:

• Evaluate Reconsiderations, investigations and CAPs to identify performance consistency opportunities.
• Ensure Reconsideration process for COI is followed and logged in accordance with PRODUCT & CUSTOMER OPERATIONS COI Policy and organization requirements
• Verify customer attestations to ensure adherence to requirements

DRIVE PROCESS IMPROVEMENT

• Participate in activities and projects to improve product and operational efficiency and effectiveness, with focus on the customer experience.
• Develop and implement sustainable training programs as indicated to advance organizational knowledge and compliance to investigative activities and inter-rater reliability.
• Strengthen onboarding initiatives through participation in new hire training related to investigative process and salesforce investigation documentation.

Primary Responsibilties:

INVESTIGATION ACTIVITIES:

• Daily oversight and appropriate escalation of investigative activities.
• Oversee sources of input including daily monitoring of CMS or other regulatory sanctions, issues raised through compliance hotline, or other notification sources. Investigate the issue and manage it through the full appropriate process, in conjunction with unit AVP and General Counsel, based on calculated risk.
  
  • Crosswalk and analyze correlation of reported activities to NCQA requirements. Look for CMS or state alignment.
  • Recommend and triage cases to leadership and Program Integrity Committee (PIC) as defined by QPI policy.
  • Implement PIC decisions, which may include detailed investigation (contact with the organization and review of materials), completion of a Discretionary Review or suspension or revocation of an organization's status.
  • Identify and assist in development, in partnership with Product Development and Policy, new or enhancement to standards based on investigations trends.
  • Establish and oversee logistics of Discretionary Reviews including staffing, timeline, communication strategy and reports
  • Provide consultation and expertise on survey-related Corrective Action Plans. Identify trends in CAP for improvement opportunities
  • Manage the annual Reportable Events / Attestation process.

CONSISTENCY AND QUALITY:

• Internal Staff and Surveyor Compliance:
  
  • Analyzing reconsideration, and investigations results and trends as well as information gleaned from discretionary review processes to inform operations leaders and staff of opportunities to better align standards or to assist in improving the customer experience. See 3. Process Improvement Responsibilities
  • IRR: Work closely with Policy, Recognition and Accreditation staff to increase surveyor interrater reliability, utilizing data driven decisions from Reconsideration, Investigations and CAP data Work to minimize the survey burden for all stakeholders. Produce monthly report to identify product opportunities or identified inconsistencies based on investigation activities and / or data analytics.
  • Manage the Reconsideration process.
    
    • Communication with organizations requesting reconsideration.
    • Analyze reconsideration submission and present analysis to Reconsideration Committee.
    • Report out reconsideration decision to organization and NCQA Report Card.
    • Annually review Reconsideration Committee membership and present to BOD for approval.
    • Recruit and orient new Recon members as needed
• DRIVE PROCESS IMPROVEMENT:
  
  • Evaluate current investigation, reconsideration and corrective action processes for operational efficiency and internal/external customer ease of use.
  • Partner with PRODUCT & CUSTOMER OPERATIONS leadership and staff to identify and support process improvement projects and / or pilots.
    
    • Serve on internal continuous quality improvement workgroups and external workgroups as directed.
    • Training and Development;
    • Implement campaigns to improve program integrity and operational effectiveness.

Requirements:

• MA/MS or a combination of education and experience that demonstrates the necessary skills and abilities required for the position.
• 3-5 years health care experience, with at least 2 years project management and QI experience.
• Knowledge or exposure to health plan accreditation process.
• Strong public speaking experience, including teaching professionals.
• Analytical skills
• Customer oriented
• Demonstrates Initiative
• Decision making
• Excellent written and oral communication skills
• Project management skills
• Planning and organization skills
• Time Management
• Facilitation skills
• Conflict resolution experience

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

NCQA is a drug free workplace. NCQA recruits, hires, trains and promotes individuals, and administers any and all personnel actions, without regard to race, color, religion, national origin, age, sex, pregnancy, citizenship, familial status, disability status, veteran status, genetic information, or other protected statuses under applicable state and federal laws.

NCQA will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c).