Specialist IIIa Accrediation & Regulatory
Florida Blue - Florida

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Job Description Specialist IIIa- Accrediation & Regulatory - 2470 Description **RE-POST PREVIOUS APPLICANTS REMAIN UNDER CONSIDERATION AND NEED NOT RE-APPLY** Job duties include but are not limited to the following: The Accreditation and Regulatory Specialist IIIa will focus on PPO, HMO and AHCA compliance to ensure that Blue Cross and Blue Shield of FL (BCBSF) dba Florida Blue is proactive with, and prepared to meet the NCQA Accreditation, and any applicable regulatory requirements. The RN in this position will have accountability for oversight and monitoring compliance with the NCQA Standards to include but not limited to; UM, Quality, Credentialing, Delegation, and Members' Rights and Responsibilities; and will communicate and implement any needed changes/updates to meet PPO, HMO, AHCA compliance.
The Accreditation and Regulatory Specialist will also function as the NCQA compliance subject matter expert/consultant for the for the following areas; Service Organizations, Care Dept., and Network Dept. to assist in ensuring full compliance with the NCQA Standards, and any applicable regulatory requirements.
Subject matter expert for Quality compliance including preparing and maintaining the Quality Improvement Program Description, the Quality Improvement Program Workplan and the Quality Improvement Program Evaluation and to ensure that all standards (NCQA & URAC), regulatory requirements (CMS, AHCA, Medicaid) and business needs are met.
Develop and implement the communication methods to ensure new processes, process changes and training are communicated to the appropriate audience internal and external departments.
Build relationships with business partners and stakeholders to assist in identifying and documenting compliance requirements into business requirements. Provides compliance consultation to management, committees, and workgroups.
Develop and implement policies & procedures that meet the compliance requirements, guidelines, governmental regulations, and state mandates. Monitor and evaluate to determine effectiveness.
Analyze data to determine trends, root causes and produce reports, memos, and whitepapers to communicate results.
Assist with negotiating contracts, review, development, and improvement of business processes for members and providers; this includes the delegated entities (practitioners and ancillary vendors). Support the transition of electronic and manual workloads to vendors and/or delegated entities.
Review sanctions, complaints, member/provider files, conduct provider profiles and correspond with practitioners to assist with the credentialing and credentialing decision.
Moderate to heavy keying required.

Job Requirements:
Bachelor's degree in healthcare or equivalent experience
4+ year’s experience in accreditation and regulatory processes RN license
Project management skills
The ability to build and maintain cross-functional business partner relationships
The ability to communicate with key internal constituents and teams
The ability to lead in monitoring and reporting of compliance status with the NCQA Standards to management and various workgroups and committees.
The ability to assist in development of policies and procedures specific to area of responsibility.
The ability to track compliance status with the NCQA Standards.
The ability to assist in preparing for on-sight reviews/audits by external entities.

Business Specific Criteria (preferred skills): Strong knowledge of and experience with regulatory and accreditation requirements
Proven proactive approach to monitoring, evaluating, and communicating potential requirements from a variety of sources.
Strong written and oral communication skills
Broad and deep understanding of healthcare delivery and ability to think strategically
Leadership ability to work with cross-functional business teams
Outstanding interpersonal, customer service, communication skills, and ability to work independently as well as a part of a team.
Team builder and player who is positive and pragmatic with a collaborative style.
Ability to navigate complex environments and achieve results through influence.
Experience with healthcare disparities/diversity/cultural competence Primary Location Jacksonville Other Locations Pensacola, Ft. Myers, Gainesville, Ft. Lauderdale, Sarasota, West Palm Beach, Tallahassee, Lake Mary, Miami, Tampa Organization Blue Cross Blue Shield of Fla Schedule Full-time Posting Deadline Mar 7, 2013, 11:59:59 PM

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