Health Care Quality and Compliance Analy
The Quality and Compliance Analyst is responsible for assessing the capability of USFHP operational departments to comply with TRICARE regulations, Department of Defense standards and contractual obligations as well as other regulatory requirements. Assists in the development of strategies to achieve compliance with applicable regulations and contractual requirements. Develops and communicates project timelines and specific project tasks when new regulatory/contractual requirements are identified. The Compliance Analyst serves as a primary contact for content experts (claims, IT, member services, operations, pharmacy, etc) regarding compliance questions and initiatives and provides tracking and trending of data to assist the Management and Administrative Teams in decision making. The Analyst is responsible for the continual maintenance and integrity of the U S Family Health Plan Compliance Program through ongoing evaluation, documentation and reporting of the current state of contract with the Department of Defense. The position works closely with external business partners to evaluate and document compliance with plan requirements according to the DoD contract and TRICARE regulations. The Analyst also participates in project teams and monitors the results of projects designed to improve the level of compliance.
The Analyst is accountable for the operation and maintenance of the US Family Health Plan Surveillance Database as well as the reporting output. Stays abreast of changes in contractual requirements and updates the US Family Health Plan Surveillance Spreadsheet as appropriate. The analyst may provide spreadsheet training and technical assistance to internal and external staff related to compliance systems or databases. Coordinates compliance data reporting activities with the Plans third party administrator (Tufts Health Plan) and with other business associates of US Family Health Plan.
The Analyst is also responsible for assisting the Quality Manager with data and reporting activities for Quality Management Committee meetings including, key performance indicators (KPI), Grievances, Appeals, Occurrences, and HEDIS statistics. Supports the U S Family Health Plan Quality Management Program through application and synthesis of data into meaningful information for action. Under the direction of the Quality Manager, the Analyst generates data and information to support decision making to improve patient outcomes, improve health care quality documentation, assure patient safety, and improve performance in patient care, treatment and services, governance, and management consistent with US Family Health Plan standards, goals, and objectives. The Compliance analyst also develops and maintains spreadsheets for the purpose of tracking, trending and reporting and may assist with preparations for DoD annual site visits, including preparing audit data and updating the USFHP Policy and Procedure manuals.
- Reviews, evaluates, designs, and implements tools for data analysis, display, and reporting.
- Accountable for designing and communicating valid and reliable data and information concerning the level of compliance of the US Family Health Plan and its business partners.
- Assists in the design of interventions to assure compliance with new Tricare requirements and develops strategies to assure ongoing compliance with current Tricare manual and contractual requirements.
- Seeks input from Manager of Quality Management for identification of compliance interventions and strategies.
- Tracks data and results for trend analysis, reporting, and identification of opportunities for improvement.
- Produces Quality Management Department reporting as indicated for Appeals, Grievances, HEDIS, NCQA, and performance improvement projects. Attends quarterly Quality Management Committee meetings as required.
- Participates on multi-disciplinary teams charged with evaluating clinical quality data and making recommendations for improvement.
- Assists with data collection for HEDIS clinical quality measures and produces health plan HEDIS measurement reports.
- Installs and maintains new systems for compliance evaluation as they become available. Identifies, recommends, and assist with implementation of quality improvement initiatives as a result of these activities.
- Provides detailed reporting and analysis on the state of compliance with TRICARE policies and contractual requirements.
- Makes available compliance status reports for each operational area/department.
- Acts as an information resource for staff and other departments within USFHP regarding quality and compliance data and information needs.
- Serves as primary contact for staff with responsibility for documenting compliance with regulatory and contractual requirements.
- Program Integrity: Assists Quality Manager with oversight of business associate compliance and prepares summary reports for the Quality Management Committee.
- Actively research literature and/or electronic media for latest healthcare statistics, standards and/or comparison data, and keeps Quality Management appraised of new and / or relevant changes in healthcare software programs.
- Performs other related duties as requested by the Manager of Quality Management and the Senior VP and Executive Director.
- Adheres to departmental as well as corporate policies and procedures.
- Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
- Commits to recognize and respect cultural diversity for all customers (internal and external) in accordance with the mission and vision statements.
- Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages.
- Provides superior customer service to internal and external clients, customers, and patients as referenced in the Service Excellence Standards, Mission Statement and Vision.
REQUIRED KNOWLEDGE & SKILLS:
- Analytical skills and the ability to interpret health care data
- Proficient in various information systems and software applications.
- Strong working knowledge of Microsoft Office and Excel database software programs.
- Ability to meet deadlines in a timely manner.
- Knowledge of managed care concepts.
- Exceptional documentation skills necessary.
- Self-directed analytical abilities; ability to synthesize data into meaningful information for action.
- Detail oriented with the ability to work independently under limited supervision.
- Ability to read, analyze, and interpret professional journals, technical procedures or government regulations.
- Strong communication skills with the ability to write reports, business correspondence, and procedure manuals.
- Ability to effectively present information and respond to questions from groups of managers, regulatory agencies, management and the general public.
- Strong analytical skills with the ability to define problems, collect data, establish facts, and draw valid conclusions
- Strong verbal and written communication skills.
- Limited travel to offsite organizations required.
- Exhibits effective interpersonal skills and professionalism.
- Education: Bachelor of Science, Business Administration Degree or equivalent education & experience.
- Experience (Type & Length): Minimum of 3 - 5 years related Health Care industry compliance, regulatory, quality &\or process improvement experience, of which at least 2 years is of an advanced analytical nature. Experience in a Managed Care Organization preferred.
- Certification/Licensure: Bachelor’s degree, Federal government statement of trustworthiness.
- Software/Hardware: Advanced Access & Excel analytical & reporting skills required. Microsoft Office and Outlook, Filemaker Pro, Visio Professional, Meditech, and IDX helpful, but not required.
- Other: Candidate must be able to successfully obtain clearance from the Department of Defense, which requires US Citizenship as part of the clearance process.