Company :
Highmark HealthJob Description :
JOB SUMMARY
This job supports risk & quality assurance studies required by regulators, the Blue Cross Blue Shield Association (BCBSA), accreditation bodies, executive management, plan partners, group customers, and employee level performance. The programs for which the department is currently wholly or partially responsible for are (a) the BCBSA's Member Touchpoint Measures (MTM), Licensee Desk Level Audit (LDLA), and Federal Employee Program (FEP) Quality Program, (b) the National Committee for Quality Assurance (NCQA), (c) Joint Commission accreditation compliance, (d) quality measures required by state regulators, (e) certain quality measures related to group and partner plan contractual performance guarantees / service level agreements, and (f) employee performance quality.
ESSENTIAL RESPONSIBILITIES
- Plan and conduct risk assessment activities according to the appropriate framework, including but not limited to MTM, LDLA, FEP, state, and contractual in order to identify, assess, prioritize, evaluate and address compliance and other areas of risk. Prepare draft reports and other management reporting deliverables. Review all work prepared by less experienced team members to ensure audit quality standards are consistently met in all forms of documentation.
- Review and interpret inherent risk assessment results, engagement risks, and develop assurance plans (e.g., on-site audit, contract review, financials assessment, purchasing data analysis) to address relevant risk areas and to ensure proper controls are implemented. Accountable for the review and interpretation of authoritative guidance and performs qualitative and quantitative impact assessments based on regulatory and contractual requirements; conducts additional information gathering and risk assessments as-needed; documents and reports results.
- Lead development of project plans to support risk assessment and decisioning in coordination with business owners and other stakeholders within task-based budgets. Collaborate and communicate with Operations, Sales, Provider, and other teams across the Enterprise to align risk management objectives, practices and procedures.
- Interface with business areas, technical staff, project teams, and third parties to execute cross-functional risk assurance projects. Lead the communication of assessment results and findings with multiple stakeholder groups and provides consultation and direction throughout.
- Interpret complex data flow/ information sharing activities, customer integrations, and information safeguards into simplified and high-level terminology and/or process/data flows. Maintains risk management reporting dashboards in RSA Archer applications in order to keep information complete, accurate, and current. Prepare and assist with the delivery of risk assurance reports to management.
- Ensure audit procedures and other risk assessments are distributed and completed on-time and prepare initial impact assessments. Ensure compliance requirements are met across the Enterprise. Assist in training and mentoring team members on multi-faceted engagements, platform customer dependencies, and interpretation of complex authoritative guidance.
- Collaborate with lead in providing input and consultation on risk and assurance reporting. Collaborate and consult with other areas (e.g., Procurement, Privacy, Information Security, Legal) throughout the engagement lifecycle Assist in providing timely feedback on interpretations regarding authoritative guidance.
- Proactively reviews updates made to departmental desk-level procedures, risk assessment methodology, assessment procedures, questionnaires, training, etc. and is responsible for monitoring compliance with departmental metrics, internal control activities, contractual obligations, regulatory requirements, and responding to customer inquiries / audits.
- Other duties as assigned or requested.
EDUCATION
Required
- Bachelor's Degree in Accounting, Finance, Business Administration/Management, Information Technology, Pre-Law, or related field
Substitutions
- 6 years of related and progressive experience in lieu of Bachelor's degree
Preferred
- Master's Degree in Accounting, Finance, Business Administration/Management, Information Technology, Pre-Law, or related field
EXPERIENCE
Required
- 5 years in Audit and Compliance
- 3 years in Operational processing
Preferred
LICENSES or CERTIFICATIONS
Required
Preferred
- Certified Public Accountant (CPA)
- Lean/ Six Sigma
SKILLS
- Demonstrate expert knowledge of business and technology processes, risk and control frameworks, and assessment methodologies, particularly as applied to healthcare (payer and provider) business processes
- Knowledge of relevant regulatory guidelines, vendor management, sourcing and procurement, and completing assessments of vendors
- Excellent resource and project planning capabilities, decision making skills, history of results