Mgr, Compliance and Quality-St. Louis or Phoenix
Magellan Health Services - Phoenix, AZ

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Mgr, Compliance and Quality-St. Louis or Phoenix (
                      Job Number: 14747 )

                      Job Summary
                      Serves as compliance/privacy officer for CMC and is manager of auditing functions. Oversee legal/regulatory compliance for business and clinical functional areas in all states where CMC manages care, including state laws and regulations, HIPAA, CMS and other federal compliance requirements.

                      Essential Functions:
                      • Oversee the implementation and ongoing operation of the Compliance Program
                      • In collaboration with the Corporate Compliance Department, implement and manage the national compliance program for SBU operations. Educate management team and staff regarding compliance and the appropriate details of the compliance program.
                      • Direct federally mandated legal/ regulatory compliance activities and those for all states where CMC is operating. Serve as a liaison for customers on legal/regulatory issues. Generate regular reports documenting operations compliance status. Ensure corrective actions are implemented for all known compliance deficiencies. These reports are submitted to Operations Leadership.
                      • Maintain expertise related to authorization/non-authorization correspondence requirements from the perspective of ERISA, NCQA, URAC, federal regulations, and state law. This includes maintaining the database of standard correspondence, modifying policies as necessary to address changes in state law or customer requests, notifying policy content experts of changes to standard policies, and working with IT regarding system changes as it relates to correspondence.
                      • Responsible for assisting the Corporate Compliance Department with materials needed for applicable state licenses.
                      • Work with Compliance Attorneys, Regional Compliance Directors and SBU operational staff in implementing federal and state laws and regulations.
                      • Serve as central contact for internal and external customers regarding compliance, security, HIPAA, and anti-fraud efforts.
                      • Work in coordination with Operations Implementations team on regulatory requirements compliance for new account implementations and for process work flows and UM correspondence.
                      • Manage the HIPAA unauthorized disclosures and breaches process with consultation from the Compliance Department. Ensure appropriate mediation plans are developed where necessary.

                      • In collaboration with the Director of Compliance and Accreditation, set priorities for procedural and customer auditing for operations and ensure that operational auditors remain dedicated to operational auditing and process improvement.
                      • Oversee reporting and distribution of findings.
                      • Develop and maintain tracking and data capture mechanisms on audits for analysis and historical archives.
                      • Serve as member of quality and process improvement management team in ensuring end –to-end quality processes for the SBU
                      • Participate in sales, marketing and account management activities as needed. Participate in staff development and training activities
                        Minimum Requirements:
                        Education: BA/BS
                        Experience: Minimum of 5 to 8 yrs

                        Equivalent combination of experience and education

                        Education and/or experience may run concurrent


                        Demonstrated leadership and management skills.

                        Knowledge of HIPAA, federal and state regulatory processes.

                        S trong interpersonal, organizational, and project management skills.

                        Ability to research, obtain, coordinate, and integrate feedback and directions from diverse operational groups and organizations into a written product.

                        Excellent verbal and written communication skills.

                        Experience in use of Lean Six Sigma methodology and tools.

                        Computer Skills: Experience and thorough understanding of word processing, flow charting, and archiving and other relevant software systems and applications.

                        Licenses, Certifications, etc.: Six Sigma certification preferred

                        Preferred Qualifications:

                        Education: Master’s Degree

                        Experience: Past experience in health care field

                        Primary Location - AZ-Phoenix AZ-4801 East Washington Street

                        Magellan Health Services is a leading specialty health care management organization with expertise in managing behavioral health, radiology and specialty pharmaceuticals, as well as public sector pharmacy benefits programs. We deliver innovative solutions to make a positive impact on the cost and quality of health care, keeping the best interests of the people we serve at the center of our decision-making. The breadth of our offerings, depth of expertise, clinical excellence and smart, talented employees is what makes us unique.

                        Magellan is the employer of choice for hard working people interested in making a difference in the health care industry and in the communities where we work and live. Our strong culture of caring is the common thread in both our business strategy and our work environment where we value professional growth and development, total health and wellness, rewards and recognition and employee unity. Magellan is a place where you can thrive.