Consultant or Senior Consultant, Part C
BluePeak Advisors, a Division of Gallagher Benefit Services is a consulting organization that specializes in providing compliance and operational consulting to MA-PD Plans and other ancillary providers and delegates. While much of the work is audit-based and focuses on the CMS Program Audit process and protocols, BluePeak also supports many other project-based process improvement initiatives that assist Plans, delegates and ancillary services providers in achieving operational compliance.
BluePeak is seeking an experienced clinician who has held leadership roles in MA-PD health plans with a preference for candidates who have worked with Special Needs Plans (SNPs) and MMPs to join our growing Part C consulting practice.
This exciting and fast-paced role is responsible for providing subject matter expertise on operational and compliance areas of Medicare Part C to effectively support BluePeak client projects. This position will support multiple client engagements as assigned which may include:
- Conduct mock program audits or assessments of CMS Program Audit areas for MAPD to include: ODAG, SNP-MOC; CMS Program Audit areas for MMP plans to include SARAG and MMPCC,
- Conduct mock audits or validation audits for Medicaid, including LTSS reviews.
- Support and guide clients under-going CMS Program Audits in the areas of ODAG, SNP-MOC and MMPCC to achieve best possible audit outcomes
- Conduct Independent Validation Audits (IVA) following CMS Program Audits for both MAPD and MMP in the areas of ODAG, SNP-MOC, SARAG and MMPCC to validate that remediation has occurred
- Review Medicare program audit protocol universes and identify potential audit issues. Provide feedback to the clients on the potential issues and remediation strategies.
- Review MAPD SNP plans Model of Care –(MOC) prior to submission to NCQA to assess compliance and accuracy and make recommendations on improvements or changes.
- Remain current on regulatory guidance and the regulatory landscape, focusing on best practices.
- Provide subject matter expertise and leadership of large-scale cross functional processes including supporting remediation activities, spearheading operational clean-up efforts and developing and implementing process improvement initiatives.
- Provide consultative guidance to plans seeking to improve quality in the areas of NCQA Accreditation, Star ratings, HEDIS
- Subject matter expertise in an operational function of Medicare Part C
- Ability to review, interpret and implement state and federal guidance
- Extensive familiarity with CMS Program audit process, universes and protocols in the areas of CPE, ODAG and SNP-MOC, MMPCC and SARAG to confirm compliance with guidance.
- Experience developing and managing quality programs including NCQA accreditation, HEDIS, Stars
- Expert understanding of compliant and effective medical management and utilization management process including appeals and grievances
- Ability to review SNP-MOC documents for quality and completeness and compliance to NCQA and CMS standards
- Ability to problem-solve in ambiguous situations and apply knowledge and experience to make decisions and recommendations for client business problems.
- Bachelor’s degree, RN with a minimum of ten (10) years government, health care, or quality profession (equivalent combination of education and experience considered.)
- Must have strong Microsoft Office Suite skills. Advanced skills in Word, Excel and PowerPoint required
- Experience with Medicare and/or Medicaid requirements and standards required
- Must have strong verbal and written communication skills.
- Individual should be detail oriented with strong organization, prioritization and analytical skills with the ability to work independently.
- Must work well under tight timelines and adapt quickly to change in a fast-paced, team-oriented, and high-growth environment.