Under general supervision, assists with the development of the Denver Health Medical Plan, Inc. (DHMP) Medicare, Medicaid and CHP+ Programs to ensure compliance with all Federal and State-level regulatory requirements. Leads and provides expert technical assistance to highly visible, sensitive, and multifaceted compliance initiatives. Provides assistance in setting strategic direction of projects, developing project plans, analytic support services and technical expertise to a board array of Medicare, Medicaid and CHP+ issues. This position will interact with all levels of management and employees, plan members, external consultants and Federal and State representatives.
Develops and drafts policies and procedures in alignment with State and Federal Requirements, ensures operationalization of policies and procedures.
Works independently and with other Managed Care Departments to compile reports, attestations, and other submissions to submit to the State and CMS/HPMS.
Creates and monitors marketing materials and content to meet CMS requirements, including member handbooks/Explanation of Coverage, regulatory notifications regarding enrollment, beneficiary rights and protections, and other mandated communications.
Compiles, analyses and ensures the accuracy of data and documentation for internal and external compliance audits.
Monitors external vendors or first tier entities that administer benefits for members, analyzing data to ensure compliance with contractual requirements
Reconciles complex sets of data received from CMS or the State in order to validate reporting, financial reconciliation, and encounter submissions to align with established goals and metrics.
Actively identifies problems and opportunities for improvement; identifies appropriate solitons and involves other in the implementation process
Ensures accuracy of data reports, develops and implements quality assurance protocols that promote continuous improvement.
Sustains collaborative relationships by facilitating communication that enhances contract/regulatory operations.
Serves as Liaison between Government Product Lines and other areas of the Managed Care Department, to interpret contractual and regulatory requirements that may assist with provider, member or other operational concerns.
Fosters and promotes meaningful dialogue with CMS Regional Office, State Agencies, and Community Partners.
Attends routine meetings, as well as those with specific focus on policy change that impacts Managed Care Departments, communicating important updates to staff/leadership.
Assists in monitoring of risk assessments, preparation and compilation of audit requirements interprets audit results; monitors daily, weekly and monthly reports.
Other duties as assigned.
Knowledge, Skills & Abilities
Critical thinking, strong written and verbal communication skills, and the ability to effectively interact within a team. Ability to develop data requirements and work with teams and groups to extract, organize and analyze data and trends. Ability to define problems: collect data, establish facts and draw valid conclusions to implement solutions. Ability to effectively present information and respond to questions from management and others. Ability to use systematic approach to problem solving and troubleshooting. Extensive knowledge of managed care/health care administration, policy and compliance. Demonstrates ability to manage multifaceted projects in conjunction with day-to-day activities. Excellent interpersonal and customer service skills, ability to work collaboratively with other corporate groups (such as Compliance Department, and Information Systems), external vendors and State and Federal entities. Self-motivated and takes initiative: identifies, acts on, and documents solutions for gaps and opportunities for process improvements. Proven ability to interpret and synthesize Federal and State regulatory requirements, ensuring policies, procedures and processes are updated to comply with guidelines.
Bachelor's Degree (Required)
1. Three years of direct health care experience with a specific emphasis on Government Health Program operations, regulatory issues, policy development, or compliance required.
Location Denver Health Medical Plan
Work Type Full time
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver's 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.
As Colorado's primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.
Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
"Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class."
Internal Number: 2299
About Denver Health
Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation’s leaders in medicine.