VP, Quality & Controls Assurance

Why This Role is Important to Us

The Vice President, Quality & Controls Assurance reports to compliance leadership, and strategically and operationally leads various quality reviews of claims, Hierarchical Condition Categories (HCC) and clinical coding, call monitoring, system technology upgrades, and other critical compliance/financial/operational controls and processes across the CCA enterprise, including all health plan and care delivery activities.

These responsibilities include planning, executing, and evaluating results of quality audits/reviews and control/operational integrity initiatives, evaluating error patterns and trends, and ensuring the reporting of relevant quality audit/review results, pre-payment and post-payment claim reviews, call monitoring reviews, and evaluation of HCC audits/reviews, among others, to relevant departments.

The role also leads the department’s focused review and internal Controls Assurance; SOX/SOC/MAR (Model Audit Rule) testing/assurance; technology/systems assurance; external and regulatory audit management, support and facilitation; and CAP remediation teams. 

The role and department evaluate statistical patterns and trends of quality and Controls Assurance results, and collaborate with owners of audited/reviewed business areas to address root causation of errors and facilitate overall quality improvement.  The leader additionally oversees special projects as identified by executive management, including but not limited to special regulatory reviews, operational/compliance control assessments, financial internal controls, and other such process- and control-improvement matters.

Supervision Exercised: Yes

What You'll Be Doing

• Leads, oversees, and develops vision, strategy, activities, and protocols for enterprise Quality & Controls Assurance Program, including the opportunity to build the program from the ground-up.
• Designs, builds, develops, assesses, and adapts clear and effective Quality Assurance and controls monitoring, audits/reviews, testing, reporting, and audit sampling methodologies to ensure proper, effective and timely assessments. Conducts regular assessments of existing quality audit protocols, activities and reports; develops new protocols as necessary; and facilitates effective remediation of findings and corrective actions.  Updates and ensures protocols and controls are followed, including timely completion of quality audits/reviews and Controls Assurance assessments.  Keeps abreast of changing industry requirements, compliance responsibilities, and regulations, including all relevant laws, rules, contractual agreements, industry standards, company practices and initiatives.  Provides clear and effective reports to the relevant business, functional and operational areas, as well as other internal/external stakeholders, regarding quality audit/review findings, contractual requirements, industry standards and best practices.
• Conducts regular and ongoing risk-based evaluation of new quality audit/review opportunities, and conducts regular evaluation of the methodology and relevance of existing audits. Oversees and directs regular gap analyses, risk assessments and program effectiveness assessments for the different Quality & Controls Assurance programs and functions.
• Establishes and ensures quality standards by designing effective quality audits/reviews and controls assessments, and selecting the most appropriate and effective sampling methodology to test quality on audited samples.
• Ensures strategic and operational partnership and collaboration with the business and operational areas, as well as with sibling Governance, Risk & Compliance (GRC) teams to leverage cross-departmental synergy and efficiencies. Develops, chairs, and leads Quality & Controls Assurance committees and working groups, ensuring that all relevant issues and data are appropriately and timely communicated, understood, aligned upon, and actioned.  Owns and performs strategic planning, goal planning, budget planning and management, performance review, professional development, and all other senior-level managerial functions for all Quality & Controls Assurance Programs, functions, and teams.
• Develops processes for identifying emerging trends through data gathering and analysis, including industry relevant AI, machine learning, data analytics, scripting, and other such automated tools, and for designing appropriate methods and tools for visual representation of analyzed data to identify trends, patterns, and results to enable effective Board, Audit Committee, and executive leadership communication and reporting.
• Ensure maximum productivity on all quality audits/reviews and controls assessments, which provide management and leadership with timely, effective, and valuable feedback. Analyze, evaluate, and present information concerning relevant factors, such as business scenarios, production capabilities, and design and development of department workflows.  Maintain databases, dashboards, scorecards, and reports of production, statistical, operational and financial results.
• Responsible for advanced topical and technical research as it relates to quality audit/review planning, internal controls assessments, and compliance with current regulatory and financial reporting requirements. Full ownership and accountability for all Quality & Controls Assurance programs, activities and reviews, including claims reviews; call center and digital communications reviews; Medicare Risk Adjustment, HCC, clinical and coding reviews; DRG and medical records reviews; technology/systems and coding upgrade and implementation reviews (e.g. final user acceptance testing, etc.); Government Programs product compliance reviews; operational reviews (e.g. enrollment and eligibility, ID cards, premium billing, EOBs, coordination of benefits, etc.); select vendor reviews; product-specific samples and reviews; focused review and internal controls testing and assurance; SOX/SOC/MAR testing and assurance; external and regulatory audit management, support, facilitation and reporting; CAP remediation oversight, support, facilitation and reporting; and GRC tool/solution, technology and data analytics implementation and utilization, among other department activities.
• Inform and advise the SVP, Fraud Risk Management & Quality Assurance and the Chief Risk, Compliance & Ethics Officer of current trends, issues, problems, and activities in functional areas, and develop and implement appropriate interventions to facilitate problem resolution and policy making. Identify critical business objectives, and develop and operationalize business plans to support critical objectives.
• Represent the Quality & Controls Assurance Department to internal and external customers and stakeholders, including regulatory agencies, to build and maintain positive relationships that support business goals and objectives.
• Perform other duties as assigned. Effectively live, role model, communicate, and support the values of CCA.  Effectively build trust, rapport, credibility, partnerships, working relationships, consensus, and coalitions with all business, operational, functional, internal and external constituents, and at all levels of the organization.  Perform in accordance with CCA competencies and behaviors.
•  

What We're Looking For

Required Education:

• Bachelor's Degree in Business Administration, Accounting, Finance or related/relevant field required

 

Desired Education:

• Graduate degree such as MBA, MA, JD and/or other advanced degree preferred

Licensing:

• CPA, CIA, CISA and/or other relevant certifications preferred

Experience Required:

• 10+ years of audit (internal and/or external), quality assurance/review, internal controls and assurance, risk management, corporate governance, compliance and/or related experience required, with heavy preference for highly substantive audit, assurance and internal controls experience.
• 6+ years of experience in healthcare industry with strong preference for health plan, managed care, government programs and payer organization focus.
• 6+ years of managerial and people leadership experience.
• Demonstrated experience in managing a substantial portfolio of audits, quality assurance reviews, internal controls reviews, remediation initiatives, concurrent oversight and execution of multiple projects, and evaluating controls associated with complex business processes.
• Experience in managing integrated audits, reviews and assessments that address a combination of financial, operational, governance/compliance, clinical and technology/systems objectives.
• Experience in executing internal corporate investigations and reviews, with a focus on internal, financial and operational controls and processes.

 

Knowledge, Skills & Abilities Required:

• Strong knowledge of and/or experience with government programs regulatory, operational, financial, and clinical requirements for the delivery of health insurance and managed care products and services, including Medicare, Medicaid, MMP, LTSS, SNP, Duals, CHIP and behavioral health, as well as the associated and relevant federal, state and local regulatory entities.
• Strong knowledge of government programs, health insurance, managed care, and payer/provider information systems, functions and continuous monitoring software to be used as tools for effectively meeting QA and internal Controls Assurance objectives.
• Direct experience with NCQA accreditation for managed care organizations preferred.
• Excellent partnership-, working relationship-, consensus- and coalition-building skills to foster and maintain highly effective relationships throughout the organization.
• Excellent communication and influencing skills, both direct and indirect.
• Strong consultative and partnership approach that strikes the optimal balance between meeting regulatory and risk management requirements, and understanding and supporting the broader macro industry, strategic, business and operational needs.
• Strategic thought leader with continuous innovation/improvement mindset and approach.
• Strong ability to interact and consult with executive leadership and potentially the Board/Audit Committee to achieve and communicate department and program goals, activities and results. Executive polish and presence.
• Strong ability to independently develop goals, action plans and contingency plans; identify resource requirements; marshal and organize resources; establish and communicate expectations; and manage multiple tasks simultaneously.
• Strong ability to effectively navigate through ambiguity and uncertainty by strategically developing a strong vision and action plan. Ability to act independently and self-sufficiently with minimal supervision or direction.
• Strong emotional intelligence required. Open, communicative, transparent, collaborative, and action-oriented leader who builds high-performing teams and department cultures and who continuously fosters strong relationships and partnerships across the enterprise.
• Strong integrity capital with commitment to doing the right thing and living/upholding organizational values.

 

Language(s):

• English

 

Other Requirements:

• Must possess exceptional Microsoft Office Skills (Word, Excel, Outlook, PowerPoint), and Internet research skills.
• Must be able to work at a desk for 8 hours/day

Actual Work LocationRemote, Boston, Massachusetts 02108
All LocationsRemote - Boston
Exempt / Not ExemptExempt