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Healthfirst Director, Clinical Vendor Management and Oversight in Remote, New York

The Director, Clinical Vendor Management Oversight is the single point of contact for all delegated medical vendor related compliance and regulatory activities and is responsible for ensuring compliance with all legal and regulatory guidelines. This position will serve as the liaison for Regulatory Affairs and Corporate Compliance for all delegated medical vendor benefit functions and UM functions.

This role reports to the VP, Clinical Business Management and Operations and includes partnering with the internal and external departmental staff and delegated vendors for identifying changing regulations and conducting regular monitoring to ensure compliance with state and federal regulations in order detect and correct compliance deficiencies.

Duties and responsibilities:

  • Serves as the point of contact with the Corporate Compliance department for all delegated medical vendor related activities.

  • Services as a liaison to internal regulatory departments for coordination of implementing new regulations and maintenance of ongoing regulatory requirements.

  • Oversee operations quality assurance program and process improvement.

  • Design, implement and oversee compliance monitoring of coverage/organization determinations, redeterminations/appeal, claims and grievances/complaints to ensure benefits and UM functions are administered according to CMS and state regulations.

  • Monitoring, analysis, and reporting of relevant quality metrics

  • Identify and recommend process improvements to better ensure compliance with federal and state regulations.

  • Keep abreast of up-to-date Regulatory issues and trends to strategically ensure that the vendors’ practices and procedures reflect industry regulatory standards.

  • Develop and oversee the progress of all delegated medical vendor related Corrective Action Plans and report to Corporate Compliance accordingly

  • Oversee the accuracy and timeliness of all delegated medical vendor internal and external reporting to Regulatory and Compliance.

  • Lead all internal and external audit requests from Regulatory and Compliance, including audit readiness.

  • Maintain accurate and compliant internal and external member and provider letters as required by regulations.

  • Collaborative with stakeholders to ensure call center operations oversight is sound and appropriately detects and corrects compliance risks.

  • Participate in all Vendor Performance and Delegated Vendor Oversight Committee activities in support of corporate Vendor oversight requirements.

  • Maintain a staff training program the keeps all staff abreast of current regulations that impact the department.

  • Participate in the delegated medical vendor Provider/vendor oversight and credentialing as required.

  • Additional duties as required.

    Minimum Qualifications:

  • 5 - 8 years of experience with compliance, regulatory, government programs and/or vendor operations

    Preferred Qualifications :

  • Relevant previous leadership experience

  • In-depth knowledge of the audit profession and auditing standards, policies, and procedures

  • Experience developing strategy and processes.

  • Experience building and managing a team and leading work processes in a fast-paced environment.

  • Time management, critical/creative thinking, communication, and problem-solving skills

  • Adept at planning, organizing, and executing.

  • Ability to build and enhance team productivity.

  • Ability to effectively manage performance as well as set and achieve goals.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement (http://www.dol.gov/agencies/ofccp/posters)

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

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