Somatus Regulatory Specialist, Value Provider Performance in San Juan, Puerto Rico
Regulatory Specialist, Value Provider Performance at Somatus
Somatus is seeking a highly motivated and detailed individual to join our growing Quality Team. This individual will be responsible for monitoring and ensuring all necessary policies, procedures, workflows, job aids and program materials related to our VBC and CKCC program are implemented and followed. This position will assist with the quality and clinical program implementations supporting the operations and other stakeholders.
Essential Duties and Responsibilities:
Support projects related to CKCC, CMMI initiatives and VBC programs to drive operational improvement, troubleshoot and impact EBITDA
Responsible for the implementation and monitoring of the organization’s quality improvement program related to VBC, MSO, and CKCC
Ensure workflow, training, and quality components are created, monitored, and implemented
Coordinate and collaborate with regulatory bodies and business partners to ensure compliance with regulatory and quality of care service requirements and inform leadership, product team, and other staff as needed of any new and/or revised regulations
Strong Understanding of CMMI initiatives as well as Value Based Strategy
Have ability to collaborate with stakeholders to identify organizational gaps for survey readiness, implementing processes to meet standards, and monitor progress for completion
Complete pre-delegation/ remediation corrective action plans
Develops audit tools, reports, standardized policies and procedures, and manuals
Surfaces and escalates any gaps in policies, procedures, or processes that may result in gaps in member care or satisfaction
Works to ensure all QI compliance related activities are successfully accomplished each year
P lease note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Required Education and Experience:
Bachelor's degree, Nursing degree
Minimum 3 years of experience with working in a value-based provider group, health plan, and/or vendor contracting with health plans delegated for services
5 years’ experience with NCQA, CMS, and other regulatory bodies
Detail oriented and excellent communication skills, including use of MS Word, Excel, and Outlook.
Strong time management and organizational skills
Knowledge, Skills, and Abilities:
Possess intermediate level of knowledge of local, state, federal laws and regulations pertaining to guidelines of provider and/or healthcare care management
Ability to document and analyze complex business requirements and processes
Experience in delegated Case and/or Care management
Experience with Navex Global and/or EthicsPoint
Experience with NCQA, CMS regulations, and accreditations
Strong analytical skills
Ability to be both a strategic and tactical change agent in the healthcare space
Self-starter who will take initiative and be proactive when there are multiple priorities
Strategic solution-seeker who sees opportunities when others see barriers
Strong interpersonal skills and ability to communicate effectively
Ability to handle ambiguity and desire to work in a fast-paced start-up environment
- This position may require up to 10 - 25% travel. Travel may be outside the local area and overnight.
This job operates in a professional setting. While performing the duties of this job, the employee is regularly required to sit or stand for extended periods of time. Normal manual dexterity is required.
Normal speaking and hearing abilities to interact with others in an office environment, over telephone or other video conferencing platform.
The employee is occasionally required to stand; walk; and reach with hands and arms and continuously repeat the same hand, arm finger motion many times as in typing.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Our priority is the health and safety of our members, colleagues, partners, and community. Proof of COVID-19 Vaccination is required for employment. If you are unable to be vaccinated for medical reasons or sincerely held religious beliefs, we will consider requests for reasonable accommodations consistent with our policy, and where we are able to provide such accommodations without undue hardship to the company pursuant to applicable law.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions .
Somatus, Inc. provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law. Further, the company takes affirmative action to ensure that applicants are employed, and employees are treated during employment without regard to any of these characteristics. Discrimination of any type will not be tolerated.