Job Description

The Health Plan Operations & Compliance Manager is an individual contributor role that initially will not manage a team, but will perform a range of duties including, but not limited to, evaluating all current and new compliance regulations, reviewing company policies and procedures, provide subject matter expertise and performing internal audits. The successful candidate will be able to multi-task and be an excellent communicator, with in-depth knowledge of health plan operations, the latest industry trends and the regulatory environment. 

Key Responsibilities:

• Thought Leadership & Innovation
  • Actively monitor CMS regulatory updates and NCQA standards as well as evolving health care industry regulatory trends and best practices in compliance programs. Work with operational and clinical internal and external stakeholders to help them understand impact of new regulations and how they can meet requirements. 
  • Develop content to communicate the updates and impact to key stakeholders.
• Product Development 
  • Ensure the MHK solutions remain compliant with applicable regulatory requirements. i.e. Medicare, Medicaid, NCQA, FEP, QHP, etc.  
  • Work alongside clinical and product team to develop requirements for needed new enhancements to meet state or federal regulations.
• Operations Support
  • Work with internal stakeholders on formulating a strategy for solutions and partner to communicate a strong vision and strategy that will help to achieve the company's objectives for growth and differentiation.  
  • Be a needed resource for MHK various team members to assist in navigating critical or challenging client escalations/discussions as they pertain to any compliance or regulatory issues.
  • Support new client implementations and existing client upgrades of MHK software solutions when needed for Utilization Management, Care Management, Pharmacy, Medical Appeals & Grievances to ensure the success of our clients to guide compliance based decisions and ensure understanding on impacts.
  • Provide ongoing subject matter expertise on the evolving care models and regulatory requirements in Medicare, Medicaid and other regulatory bodies.
  • Lead communication of the importance of compliance and any changes to regulations that will be shared with clients.
  • Facilitate internal audits to ensure ongoing compliance with MHK policies.
  • Assist clients with CMS program audits and NCQA accreditation preparation.
  • Adapt to competing demands, take on new responsibilities and adjust to meet changing priorities. 
  • Maintain client PowerPoint presentations that outline identified regulatory updates.
  • Back up Compliance Officer when needed for daily operations 

Skill Requirements:

• Five (5) years proven experience in leading health plan/managed care operations with utilization management, appeals, grievance, pharmacy, case management or quality management. 
• Strong knowledge of CMS, Medicaid, QHP and federal regulations and CMS audit experienced 
• Outstanding communication and interpersonal abilities
• An analytical mindset with exceptional organizational skills
• Firsthand experience with operational procedures, reporting and auditing
• Methodical and diligent with outstanding planning abilities
• An analytical mind able to “see” the complexities of procedures and regulations
• Experience researching and summarizing applicable regulatory requirements
• Ability to write updates and memos to C-suite level internal and external clients
• Superb written, verbal communication and interpersonal skills
• Excellent in the use of Microsoft applications

Education Requirement: 

• Bachelor’s Degree / Associates Degree or relevant work experience 

Other Skills/Abilities:

• Must be able to take initiative and be able to identify issues requiring escalation and drive to resolution
• Must be able to prioritize workload multiple times a day 
• Experience identifying key metrics and cross-walking regulatory requirements
• Excellent interpersonal and communication skills (written and oral)
• Strong organization and prioritization skills with ability to handle multiple tasks 
• Exhibits honesty and integrity
• Self-motivated, Self-directed
• Critical thinker
• Analytical skills
• Tact and positive demeanor
• Dedication to a high degree of customer service 
• Conflict resolution/ problem solving skills 
• Team player/team builder/coach

Location:

• Position based at the Tampa, Florida, office.  Collaboration onsite at least 2 days per week is expected. 

At MHK we help health plans and pharmacy benefit managers deliver optimal care management across every member’s health journey.  We do this through state-of-the-art technology that provides critical insights from member enrollment and maintenance through every stage of care and compliance. 

Benefits Snapshot:

• Medical, vision, and dental plans for full time employees
• 401(k) offered with a generous match
• Benefits begin on first day of the month following employment   
• Exercise/Health Club reimbursement opportunity 
• Monthly dependent care reimbursement opportunity 
• Short Term and Long Term disability 
• Basic Term Life and AD&D Insurance 

Paid Time Off

• 18 days Paid Time Off  
• 15 Company Paid Holidays 

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