Job Details

Quality Regulatory Specialist - PHP

CareOregon, Portland, Oregon

Full Time - Health

Salary Range: DOE

Close Date: 10/09/2020

The Quality Regulatory Specialist for Population Health Partnerships (PHP) is responsible for coordination, monitoring and evaluation of various regulatory requirements from Centers for Medicare and Medicaid Services and Oregon Health Authority. This position is responsible for the oversight of quality audit preparation and oversight activities within population health services in alignment with organizational policy and regulatory requirements. Also, this role will provide support, coordination, tracking and reporting to support the administration of Population Health Partnerships care coordination processes as required by state, county and federal regulations.

Essential Position Functions

Regulations and Audits

  • Coordinate and track Population Health Partnerships care coordination regulations, audit and compliance activities.  
  • Responsible for coordination, monitoring and evaluation of various regulatory requirements from CMS and OHA.
  • Audit preparation files, findings and activities.
  • Manage and participate in audit and compliance activities related to quality assurance and improvement meetings.
  • Collaborate with others within the organization to coordinate self-audit practices.
  • Participate in the development and execution of the process for external quality reviews across the department as it relates to programs such as Model of Care, as well as OHA audits.
  • Assist Audit and Compliance in the preparedness for CMS audits across the organization.
  • Attend and participate in internal and external meetings related to quality regulatory requirements.
  • Guide staff responsible for vendor and delegated monitoring and audits to reach department goals and regulatory compliance.
  • Ensure policies are understood and clearly communicated in relation to quality and compliance requirements; recommend policy changes in collaboration with department and organizational quality leadership.
  • Work collaboratively with operational and clinical leaders across CareOregon to support the quality work plan, including overseeing and monitoring completion of specific tasks/function.
  • Coordinate, monitor, evaluate, and track Medicare and Medicaid activities, processes and/or contractual obligations as defined by leadership.

Program Administration

  • Monitor and coordinate with vendors and delegates, as applicable, and may work with other vendors and contracts as assigned by the PHP Department. 
  • Provide guidance and oversight to the vendor to ensure compliance with the vendor’s contract and delegation agreement (when applicable), including monitoring performance, escalating issues internally and with the vendor.
  • Manage files and communication with vendors
  • Support the administration of CareOregon’s Medicare Advantage plan and Medicaid plan to accomplish compliance with state and federal requirements.
  • Develop/maintain a tracking and calendar system which may involve working with internal stakeholders.
  • Collaborate with others within the organization to ensure the integration of assigned activities with other organizational projects, as directed.
  • Collaborate with other CareOregon programs and departments to gather, share, and interpret reports and findings.
  • Oversee monitoring and reporting of population health services and performance with both a clinical and quality assurance lens.
  • Maintain confidentiality of all discussions, records, and other data in connection according to professional standards.
  • Ensure processes align with internal policies and external regulations.
  • Identify opportunities to increase efficiency and standardization across PHP services.
  • Ensure that population health quality deliverables are visible to all stakeholders and have systems in place to track deadlines, project deliverables, and ability to articulate what quality requirements are and how networks programs can address and/or meet.
  • Provide support to and participate in multidisciplinary workgroups.
Complete details: CareOregon Careers