Lead Business Operations Support Specialist

Summary of Position

• Responsible for ongoing business support of the Operational functions, including new or revised product implementations, accreditation, contracts, compliance requirements and internal and external regulatory or client audits.
• Lead and support implementations of new processes within operations, interfacing with Product, Accreditation, Provider Network Management and Compliance counterparts as well as overseeing and driving initiatives at the direction of the Tower Leads; oversee ongoing progress.
• Direct and guide operational areas on compliance measures, providing subject matter expertise and guidance for all matters relating to business functions, accreditation/quality and compliance requirements

Principal Accountabilities

• Develop and oversee annual Operations Business Support work plan, which includes documenting and tracking all initiatives and requirements, assessing projects, timelines and risks.
• Develop, initiate, maintain and update policies and procedures for the operations aspects of Product, Accreditation, Contracts and those that support regulatory requirements.
• Drive and direct implementation of day-to-day operations controls. Maintain current knowledge of changes in products, accreditation standards, industry rules and regulations and assist in maintaining effective lines of communication with other departments to ensure alignment.
• Act as an independent review and evaluation body to ensure that Product, Accreditation, Contractual and compliance issues and concerns are being appropriately evaluated, investigated and resolved.
• Monitor and oversee business activities of other departments that Operations interfaces with to maintain an end-to-end process view of all products, business, quality and compliance activities and to identify trends that cross-functionally impact the organization.
• Interface directly with the Operations Audit team, Corporate Compliance, Account Management, Quality and Operations team(s) to manage regulatory audits and monitoring events, accreditation reviews, and internal or client-based audits. Direct universe generation, preparation of sample files and corrective action plans as needed.
• Act as Operations lead for program audits; proactively prepare Operations, direct Analytics and reporting team on data validation requirements, perform mock audits and assess risks. Work in conjunction with Operations leadership and teams to provide root cause analysis, corrective action plans and execution/implementations therein.
• Conduct routine meetings with Operational partners and attend other business area meetings, such as Product Implementations, Annual Renewals, NCQA Workgroups and Compliance work groups to serve as an Operations liaison.
• Actively support and lead process improvement initiatives that lead to cost savings, improved experience and maximization of administrative resources.
• Lead projects as needed; perform other related tasks as directed or required.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor’s degree in Business, Health Administration or related field required; graduate degree, preferred. Additional years of experience may be considered in lieu of educational requirements
• Certification in HealthCare Compliance (CHC) or equivalent preferred

Relevant Work Experience, Knowledge, Skills, and Abilities

• 5 – 8+ years’ experience in positions of increasing complexity/responsibility, preferably in a managed care environment required
• Experience in Healthcare Operations, Product, Accreditation and/or Compliance required
• Extensive knowledge of CMS, DOH and DFS compliance requirements required
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience required
• Technologically literate - familiar with IT focused frameworks, systems and methodology required
• Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, Visio, etc.) required