Director, Operations Quality Assurance

The Director Operations Quality Assurance leads an operational audit team which works with business partners to audit compliance related and business health indicators, identify errors for both areas, and ultimately partner with business leaders to identify, implement and monitor technology and data-driven solutions. The incumbent contributes to our business growth and effectiveness by leading operational audit teams’ performance, procedures, and reporting and continually strategizing how best to measure adherence to operational standards. He/she ensures Healthfirst remains regulatory compliant by understanding, interpreting, and ensuring the timely implementation of all new and revised reporting requirements by Centers for Medicare & Medicaid Services (CMS) and New York State (NYS) Regulatory agencies. The incumbent partners closely with regulatory, compliance, operations (i.e., Contact Center Operations, Enrollment and Billing, Claims Operations, etc.), claims audit business analytics, and IT to ensure the collective is working in concert in support of regulatory adherence.

Duties/Responsibilities:

· Design and execute the operations internal audit strategy to assess financial, operational, and compliance risks

· Lead a team responsible for performing a variety of operational audit functions across business teams, including identifying new and innovative methodologies

· Develop talent to meet departmental objectives

· Conduct regular audits on various operations departments and processes to ensure compliance with regulatory standards and internal policies

· Lead, coordinate, and actively participate in managing audit planning, conducting audits, preparing audit evidence, assessing the quality of audit evidence, and ensuring audit readiness for Operations audits

· Contribute to executing onsite and/or desk audits and collecting anticipated audit findings

· Identify control weaknesses, potential risks, and opportunities for process improvement

· Work closely with external auditors and regulatory bodies, ensuring alignment in audit findings and follow-up actions

· Develop and implement quality assurance frameworks and standards across various operations

· Oversee quality assessments to ensure that customer service, claims processing, and other critical functions meet defined quality benchmarks

· Institute reporting and analytics capabilities that provide insights and trends, performance improvement recommendations, sound statistical sampling and audit source data

· Help evaluate technology solutions to identify solutions offering workflow improvement, reporting, analytics, and AI

· Assist in identifying and implementing robust automated systems to obtain, aggregate and house results with real-time and on-demand reporting

· Analyze data from quality assessments to identify trends, areas of improvement, and training needs

· Work with departments to establish performance metrics and monitor adherence to quality standards

· Ensure compliance with healthcare regulations and industry standards, addressing changes in regulatory requirements

· Recommend process improvements to enhance operational efficiency and reduce errors or compliance issues

· Keep abreast of industry issues and trends to proactively shape Internal Audit, Quality Assurance and Testing practices and procedures

· Collaborate with external vendors, ensuring SLAs are met along with all contractual obligations

· Additional duties as assigned

Minimum Qualifications:

· Bachelor's degree from an accredited institution or relevant experience

· Work experience requiring knowledge of an array of NYS and federal rules and guidelines that impact Contact Center Operations, Enrollment and Billing and Claims operations for Medicaid, Medicare, and Commercial lines of business (i.e. contract laws, prompt pay, etc.)

· Work experience requiring knowledge of Medicaid and Medicare

· Previous management and oversight experience of regulatory and compliance initiatives

Preferred Qualifications:

· Substantial experience leading complex, operations-wide initiatives and the development and implementation of impactful audits and root cause analyses

· Science and research-based knowledge in a variety of topics related to operational audits

· Strong facilitation, consulting, and influence skills across a variety of audiences

· Exceptional verbal and written communications and content: concise, clear, simple, visually appealing

· Proven ability to manage and collaborate with senior stakeholders and across operations teams

· Project management experience

· Power BI Microsoft software tool

Compliance & Regulatory Responsibilities: Noted above

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.