ACD Program Integrity Lead

Profile

Description

This role has responsibility for the oversight and monitoring of the Autism Care Demonstration (ACD) team performance to ensure compliance with contract and complex ACD policy requirements as defined by the TRICARE Operations Manual (TOM), Chapter 18 Section 4.

Responsibilities

The Senior Compliance Professional responsibilities include analyzing data, reporting findings and working with leadership to identify and implement changes as needed. Requires cross-departmental collaboration, conducts briefings and work area meetings; maintains frequent contact with managers across the department. Reviews documentation in all areas/systems utilized by ACD associates to assure performance compliance. Advises leadership to develop functional strategies on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of action.

Humana Government Business government contract requires U.S. citizenship for this position .

KEY ACCOUNTABILITIES

30 % Ensures performance compliance with all ACD requirements as outlined in TOM Chapter 18 Section 4 for all functions, identifying and addressing challenges of diverse scope and complexity. Demonstrating cross-departmental collaboration, conducting internal briefings and area meetings. Maintains frequent contact with other managers across the department. Notifies leadership as necessary on the need for functional strategies to address significant issues.

25 % Demonstrates understanding of the ACD policy requirements and Program Integrity policies, procedures and workflows to operationalize this very complex policy. Reviews associate documentation, analyzes data findings and briefs team on findings to work collaboratively on developing and implementing necessary corrective actions. Decisions may relate to resources, approach, tactical operations and initiatives involving own departmental area.

20 % Uses independent judgment, researches compliance issues to determine root cause and the best course of action. Recommends changes to assure compliance with contract obligations. Maintains relationships with stakeholders. Coordinates implementation and compliance with corrective action plans, as needed.

20 % Works collaboratively with other ACD stakeholders such as CM, UM, QM, PA, Government Services and Claims Oversight to provide consultative assistance, participate in integrated care planning and determine way ahead.

5% Other duties as required.

This role description in no way states or implies that the key accountabilities above are the only ones being performed by the individual(s) with this role description. The individual(s) may be called upon and required to follow other instructions or perform other duties and tasks requested by his or her supervisor, consistent with the purpose of the position, department and/or company objectives .

Required Qualifications


3 plus years of healthcare fraud investigation experience
2 plus years of technical experience with SQL server and integration services
TRICARE knowledge and experience
Experience in healthcare or in a managed care setting
Experience with Microsoft Office products for business presentations including; Word, Excel, PowerPoint, Visio and/or Project
Excellent verbal and written communication and PC skills
Demonstrated success in planning and implementation of across-the-board process improvement initiatives, including both tactical and strategic-level projects
Ability to think analytically, apply analytical techniques, and to provide in-depth analysis of technical process, business process, or raw data and recommendations to management using critical thinking and sound judgement
Our Department of Defense Contract requires U.S. citizenship for this position
Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)


Work at Home Requirements


Must have a separate room with a locked door that can be used as a home office to ensure you have absolute and continuous privacy while you work
Must provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required


Preferred Qualifications


Database performance management/monitoring/reporting experience with Microsoft SQL Server, SQL Stored Procedures
2 or more years of Management experience
Direct or indirect experience with the TRICARE Autism Care Demonstration
Bachelor's degree
Prior experience in compliance or auditing
Lean; Six Sigma Certification
Prior experience with Care Management operations support
Expertise and experience in project management, program management, problem solving and issues mitigation


Additional Information

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

Company info

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