Senior Process Improvement Specialist (Remote)

PURPOSE :

The role will support the division and corporate compliance in the delivery and performance of a compliance program to help ensure compliance and alignment with Federal, State, and related regulatory statutes, as well as company policies for CareFirst plans.

ESSENTIAL FUNCTIONS :

Reviews complex business processes, systems, reports, workflows, to identify, document, and elevate the presence of risks and trends within, that may be non-compliant with contracts and or statutory requirements; or opportunities for process improvement.

Provide regular investigative, analytic and audit reporting data to stakeholders.

Ensure documentation is developed and maintained to support progress of projects.

Analyzes and aligns functional area policies, procedures, SOPs, and tools to help ensure they comply and align with regulations and remain updated and current.

Supports the development and manage a compliance program, including development, review, approval and implementation of division and department policies and procedures toachieve greater efficiencies and effectiveness.

Performs audits, inquiries, reviews, and monitoring to help ensure processes and activities are in compliance, including review of processes, controls, and samples for key functions and Delegation oversight to remove risk or exposure.

Analyzes and audits controls for strengths and weaknesses and ensures that special focus is allocated to the specific risk areas creating the highest exposure to the division.

Works with division’s management to establish and implement corrective action plan as an outcome of any audit findings.

Monitors, assesses, and reports significant matters to senior management.

Support the Division's Embedded Compliance department in driving accountability for Compliance activities and in support of the achievement Divisional goals.

Acts as a liaison across divisional areas and corporate compliance, providing communication, channels for questions / concerns, and support for corporate and compliance efforts.

Ensure training content incorporates necessary procedures, SOPs, workflows, etc. applicable to the policies.

Ensure required CareFirst compliance responsibilities are fulfilled for the Division, including, but not limited to annual trainings, certifications, and statutory deadlines.

SUPERVISORY RESPONSIBILITY :

Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.

QUALIFICATIONS :

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
• The requirements listed below are representative of the knowledge, skill, and / or ability required.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level : Bachelor's Degree, Management, Business, or other healthcare related degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience : 5 years Experience in quality management / improvement, internal auditing, Business process engineering, program evaluation or health care accreditation.

Preferred Qualifications :

Healthcare Compliance certification(s)

Experience in CMS programs (Medicare or Medicaid, project management, business process analysis, work flow, and task analysis.

Process Improvement Systems training in Six Sigma, Lean, or other Business Process Improvement tools.

Licenses / Certifications :

Knowledge, Skills and Abilities (KSAs)

Travel Requirements :

Estimate Amount : 5% Travel to CareFirst locations or training may be necessary

Department

Department :

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.