The Quality and Compliance Manager will serve as the leader responsible for managing aspects of the clinical quality, compliance and auditing needs of the Care Management program at Bright Health. Will manage, monitor, and maintain success for all aspects of clinical quality and compliance regarding Chronic/Complex Care Programs, Special Needs Plans Model of Care, and other Care Management programs. This role will ensure all standards and program requirements are understood, implemented, and followed by monitoring/auditing documentation, program outcomes and Care Partner participation. The Quality and Compliance Manager will provide support to management to create needed process improvement, address any quality or compliance concerns and support retraining of staff as needed. In collaboration with the Associate Vice President and the Bright Health Compliance Department, monitor, manage and assist with any CMS or other regulatory agency auditing functions.

ROLE RESPONSIBILITIES
The Quality and Compliance Manager job description is intended to point out major responsibilities within the role, but it is not limited to these items:

1. Serves as the point of contact, coordinating and collaborating with regulatory bodies and business partners to ensure compliance with regulatory and Health Plan quality of care and service requirements.
2. Lead audit preparation
3. Attends committee meetings as required to provide incoming and outgoing reporting on audit results and corrective action
4. Assist with the development, implementation and monitoring of the health plan, NCQA, URAC, and CMS requirements. The program should include creating systems for peer review, health plan reporting, auditing, guidelines development, disease management, outcome studies, grievance resolution and medical education
5. Maintain passing scores for annual health plan audits and ensure corrective actions, if any, are performed timely and forwarded to health plan representative.
6. Assist with the policy and procedures updates, as necessary.
7. Tracking of Corrective action plans and deliverables
8. Coordinates and gathers documentation to respond to audits conducted either internally or externally
9. Develops tools that assist in determining exposure to clinical quality compliance risks. Identifies opportunities to manage and mitigate those risks.
10. Provides guidance and oversight to business unit audit functions to ensure ongoing clinical quality compliance and monitors corrective action plans relating to quality improvement and compliance.
11. Monitors development and use of metrics for clinical quality compliance.
12. Collaborates with teams across Bright Health on clinical quality compliance initiatives.
13. Collaborate, authors, and provides support to all SNP products including MOC Chapter 4 Development and Management
14. Other duties as assigned

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
• Requires BS/BA
• RN preferred
• 3 years of experience in Case Management including compliance or accreditation, and auditing experience; or any combination of education and experience, which would provide an equivalent background preferred
• Strong knowledge of Medicare preferred. Healthcare data analysis experience preferred.
• Proficiency with Microsoft Excel, Word, Power Point and Outlook required
• Ability to travel may be required.

LICENSURES AND CERTIFICATIONS
• Active RN license preferred

WORK ENVIRONMENT
The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Some travel may be required.