Senior Specialist, Network Compliance Oversight - Remote

Summary of Job

Ensure compliance of all regulatory mandated print directory and associated materials for the company's provider network. Facilitate updates to the print Provider Network Directory to ensure it is accurate, up-to-date, and complete: responsible for development to production for all lines of business; serve as a subject matter expert providing feedback, recommendations, analysis and development from inception to completion. Collaborate on Provider Network regulatory communications as well as Vendor and Delegate oversight.

Responsibilities

• Participate in all phases of project planning and process management of the printed provider network directory updating; ensure that all materials are current, accurate, and in compliance with all applicable regulations.
• Serve as the Subject Matter Expert for print provider network directory development and production for all products; provide guidance on regulatory requirements for directory accuracy and inclusion of compliance requirements.
• Perform research, comparisons, audits, and analysis; define process and project needs in terms of scope, timelines, deliverables, stakeholders, resource allocation, etc.
• Build rapport with and influence stakeholders for effective cross-functional and department collaboration; organize different individuals, stakeholders, and business leaders (internally and externally) around shared goals.
• Work with project team members to manage information outreach, including specific objectives, timelines, and key deliverables. Follow through on defined directory production scope by developing timelines, objectives, deliverables, and project plans; providing updates (including dashboards and tracking documents) on progress status and risks to ensure that directory production stays on track.
• Provide feedback on progress of projects, regularly providing recommendations; compile and present results of analyses to appropriate parties; and develop and prepare materials that reflect progress and track the printed directory production.
• Work with the Product teams to manage the production for all lines of business and for implementing and maintaining the requirements of the printed directory production for each product; and memorialize each production.
• Serve as the primary contact with third party vendors that produce the printed directories.
• Facilitate the transfer of data files from EmblemHealth systems to the vendors.
• Work with IT throughout the print production process to ensure timely and accurate file transfers.
• Responsible for Provider Network regulatory communications to include reviewing reports from regulatory entities (i.e. DOH, CMS, etc.) noting deficiencies and facilitate information gathering, remediation, and draft response to the regulatory entity. This includes outreach within PNPH, creating and managing trackers, and ensuring timely and complete responses for executive signature and submission to regulators.
• Receive and facilitate responses to regulatory reports, inquiries, and standard data submissions.
• Identify, anticipate, prevent, and mitigate/resolve issues and obstacles that impede project completion.
• Memorialize responses; create and maintain trackers of all reports and responses. Monitor trends and repeat findings to establish root causes.
• Support and monitor the organization's delegated vendors and providers to ensure contract, Quality, and regulatory compliance.
• Maintain the oversight structure for delegated and other key vendors by managing the SharePoint site, facilitating annual updates of the oversight documents and processes, and auditing for completeness and accuracy to support NCQA and regulatory audits and exams.
• Coordinate the bi-monthly Delegate and Vendor Oversight Committee meeting; ensure proper documentation of oversight activities. Maintain the oversight structure for delegated and other key vendors by managing the SharePoint site, facilitating annual updates of the oversight documents and processes, and auditing for completeness and accuracy to support NCQA and regulatory audits and exams.