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Consultant or Senior Consultant, Part C

Backgrounds

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.

Job Summary

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

Experience

  • 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.

Qualifications

  • 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.

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Consultant or Senior Consultant, Part C

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