Compliance Manager

For more than 20 years, WINFertility has been managing family-building benefits that are delivered with care and support by the highest quality providers. WIN is the largest, most experienced fertility benefit management company in the country. It offers inclusive family-building solutions to employers, health plans and individual patients. From integrated fertility management, including medical treatment, pharmacy and reproductive genetics, to surrogacy and adoption, WIN’s mission is to help build families by providing access to the best network doctors, technology and emotional support at the lowest cost.

WIN’s managed fertility programs include an integrated medical and pharmaceutical model that is unique to the industry. Its dedicated nurse care managers, all with experience in reproductive endocrinology clinics, guide employees through every step of their fertility journey, and are available 24/7.

The Compliance Manager is responsible for coordinating and performing all pre-delegation and annual due diligence audits and monitoring of delegated activities to ensure compliance with National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), contractual agreements, and State and Federal requirements. Oversees the licensing & credentialing function which ensures all company licensure (e.g. utilization management, third party administrator) and provider credentialing requirements are met and maintained per WIN Policies & Procedures, state regulatory requirements, and contracted health plan directives.

ESSENTIAL FUNCTIONS

• Coordinate all facets of the URAC and NCQA accreditation/approval process including ensuring all activities, documentation and evidence necessary for the accreditation are prepared in compliance with accreditation standards
• Assist in training in current URAC standards as appropriate to job functions
• Serve as a resource for other departments for compliance with accreditation standards
• Implements compliance programs, policies and procedures designed to ensure compliance with all applicable federal laws, regulations and delegation requirements
• Analyzes delegation audit results and makes recommendations for improvement
• Identifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/ or deficiencies. · Prepares audit files for submission as required
• Participates in delegation audits, supplying information as needed
• Performs tasks related to external audits from contracted health plans/employer groups as well as pre-delegation review with potential health plans as required
• Coordinates with delegated partners to ensure adherence to all regulations, contractual agreements, NCQA, and URAC guidelines
• Follows up on corrective action plans ensuring timely closure
• Prepares adverse determination notices in compliance with regulatory requirements
• Demonstrates proficiency in the application of health plan/employer group guidelines and nationally recognized review criteria
• Demonstrates a solid understanding of utilization management
• Reviews and adheres to department policies and the Utilization Management plan
• Conduct standard random audits and focused audits to determine compliance to departmental standards
• Supervises the licensing and credentialing function to ensure requirements are met and maintained
• Support HIPAA Privacy Officer in executing responsibilities
• Perform other duties as assigned.

SUPERVISORY RESPONSIBILITIES:

Currently no supervisory responsibility.

MINIMUM QUALIFICATIONS

• Clinical degree or Bachelors’ degree preferably in health care related field
• Minimum of 2 years of healthcare compliance experience
• Minimum of 2 years of utilization management experience with working knowledge and understanding of basic utilization management and quality improvement concepts preferred

KNOWLEDGE, SKILLS AND ABILITIES

• Knowledge of (NCQA), Utilization Review Accreditation Commission (URAC) and other general accreditation standards

WIN offers our employees competitive and comprehensive benefits to include but not limited to:

• Paid vacation, sick and holiday time
• Medical
• Dental
• Vision
• Life Insurance (company paid and supplemental)
• Disability Insurance
• Health Savings Account (HSA) with a per month company contribution
• Flexible Spending Account (FSA)
• Transit Account
• 401k plus company match
• Pet Insurance

WIN Perks and Plum Benefits

• Employee Assistance Program
• Free access to Fitness Center at our main office location
• Free indoor parking at our main office location
• Transit Account
• Knowledge of health plan programs and managed care
• Experience using MS Office products including Word and Outlook

Job Type: Full-time

Job Type: Full-time

Pay: From $1.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Schedule:

• 8 hour shift

Experience:

• Utilization Review Accreditation Commission (URAC): 2 years (Required)
• Quality assurance: 2 years (Required)
• Healthcare compliance: 2 years (Required)
• Utilization Management: 2 years (Preferred)

Work Location: In person

Salary : $1 - $0