UM Regulatory & Compliance Analyst

This position provides support and coordination for the Utilization Management Department in maintaining a constant state of readiness for and compliance with regulatory, and accreditation requirements.

This includes organizing, planning, tracking, documenting, and implementing various activities and projects to ensure the department’s ability to demonstrate compliance and quality.

UM Regulatory & Compliance Analyst facilitates projects to support continuous improvement in systems and processes. Provides project management, group process skills, data collection and analysis and process improvement skills.

ACCOUNTABILITIES :

Maintains a thorough and comprehensive understanding of state and federal regulations, accreditation standards, member contracts and Health Plan policies and procedures in order to provide interpretation, promote consistency and support compliance.

Reviews (specified) written department materials, editing and revising them as needed to provide uniformity and usability;

establishes standards as appropriate.

Supports regulatory compliance by routinely Analyzing compliance data from department programs, creates reports and recommends next steps to reduce compliance risk and assure a constant state of audit readiness.

Accountable for all aspects of Utilization Management / Utilization Review (UM / UR) delegation oversight.

Revises and maintains UM / UR Policies and Procedures and ensures compliance with current regulatory and accreditation standards.

Supports maintenance of effective training materials related to current regulatory and accreditation standards / requirements with focus on risk management.

Coordinates with other departments such as Government Programs and Corporate Integrity as needed.

Supports regulatory and accreditation audits including universe file pulls, file preparation and submission of documentation as needed.

Willingly participates in and / or effectively leads various committees, workgroups, and projects as needed and assigned.

Maintains appropriate confidentiality of information in accordance with HealthPartners corporate policies.

Participates in ongoing independent study and education to develop and maintain knowledge in the areas of applicable software systems, regulatory and accreditation standards and quality improvement strategies.

Demonstrates effective project management skills, including use of project planning and tracking tools; development of achievable goals, objectives, and timelines;

and innovative use of resources.

Actively pursues professional development to continuously enhance knowledge and skills.

Demonstrates responsiveness to and appreciation of constructive feedback and recommendations for personal growth and development.

Performs other duties as assigned.

REQUIRED QUALIFICATIONS :

Bachelor’s degree in Business, Health Care Management or related field.

3 years relevant experience in program compliance, utilization review, utilization management or case management

Demonstrated comprehensive, in-depth knowledge, of regulatory and accreditation compliance requirements, with ability to interpret standards and implement processes accordingly.

Demonstrated ability to work collaboratively and communicate with staff at all levels within the organization and externally.

Group presentation experience

Excellent customer service skills and proven team building skills.

Proficiency with Microsoft Office Suite of products (Word, Excel, PowerPoint, MS teams)

Excellent technical and business writing and editing skills

Demonstrated analytical skills using computer system (spreadsheets) and ability to apply appropriate basic statistical tool to data.

Strong problem-solving skills

High degree of initiative and ability to work independently, and within a group.

Demonstrated effective project management skills

Ability to plan, organize and prioritize work effectively, including the flexibility to accommodate frequent changes.

PREFERRED QUALIFICATIONS :

HMO or Managed Care experience

Previous experience in HealthPartners Medical Management

DECISION-MAKING :

Performs independently within scope of accountabilities.

Prepares risk management mitigation strategies and proposes recommendations to various levels of leadership.

Articulates business needs and translates to educational programs that result in targeted staff competencies.