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Location : 1 American Ln, Greenwich, CT 06831
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Job Description : ABOUT USFor more than 20 years, WINFertility has been managing family-building benefits that are delivered with care and support by the highest quality providers. WIN is the largest, most experienced fertility benefit management company in the country. It offers inclusive family-building solutions to employers, health plans and individual patients. From integrated fertility management, including medical treatment, pharmacy and reproductive genetics, to surrogacy and adoption, WIN’s mission is to help build families by providing access to the best network doctors, technology and emotional support at the lowest cost.WIN’s managed fertility programs include an integrated medical and pharmaceutical model that is unique to the industry. Its dedicated nurse care managers, all with experience in reproductive endocrinology clinics, guide employees through every step of their fertility journey, and are available 24/7.The Manager of Compliance is responsible for coordinating and performing all pre-delegation and annual due diligence audits and monitoring of delegated activities to ensure compliance with National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), contractual agreements, and State and Federal requirements. Oversees the licensing & credentialing function which ensures all company licensure (e.g. utilization management, third party administrator) and provider credentialing requirements are met and maintained per WIN Policies & Procedures, state regulatory requirements, and contracted health plan directives.ESSENTIAL FUNCTIONSCoordinate all facets of the URAC and NCQA accreditation/approval process including ensuring all activities, documentation and evidence necessary for the accreditation are prepared in compliance with accreditation standardsAssist in training in current URAC standards as appropriate to job functionsServe as a resource for other departments for compliance with accreditation standardsImplements compliance programs, policies and procedures designed to ensure compliance with all applicable federal laws, regulations and delegation requirementsAnalyzes delegation audit results and makes recommendations for improvementIdentifies and communicates with appropriate departments, teams, and key leadership on internal audit results and/ or deficiencies. · Prepares audit files for submission as requiredParticipates in delegation audits, supplying information as neededPerforms tasks related to external audits from contracted health plans/employer groups as well as pre-delegation review with potential health plans as requiredCoordinates with delegated partners to ensure adherence to all regulations, contractual agreements, NCQA, and URAC guidelinesFollows up on corrective action plans ensuring timely closurePrepares adverse determination notices in compliance with regulatory requirementsDemonstrates proficiency in the application of health plan/employer group guidelines and nationally recognized review criteriaDemonstrates a solid understanding of utilization managementReviews and adheres to department policies and the Utilization Management planConduct standard random audits and focused audits to determine compliance to departmental standardsSupervises the licensing and credentialing function to ensure requirements are met and maintainedSupport HIPAA Privacy Officer in executing responsibilitiesPerform other duties as assigned.SUPERVISORY RESPONSIBILITIES: Currently no supervisory responsibility.MINIMUM QUALIFICATIONSClinical degree or Bachelors’ degree preferably in health care related fieldMinimum of 2 years of healthcare compliance experienceMinimum of 2 years of utilization management experience with working knowledge and understanding of basic utilization management and quality improvement concepts preferredKNOWLEDGE, SKILLS AND ABILITIESKnowledge of (NCQA), Utilization Review Accreditation Commission (URAC) and other general accreditation standardsWIN offers our employees competitive and comprehensive benefits to include but not limited to:Paid vacation, sick and holiday timeMedicalDentalVisionLife Insurance (company paid and supplemental)Disability InsuranceHealth Savings Account (HSA) with a per month company contributionFlexible Spending Account (FSA)Transit Account401k plus company matchPet InsuranceWIN Perks and Plum BenefitsEmployee Assistance ProgramFree access to Fitness Center at our main office locationFree indoor parking at our main office locationTransit AccountKnowledge of health plan programs and managed careExperience using MS Office products including Word and OutlookJob Type: Full-timePay: From $85,000.00 per yearBenefits:401(k)401(k) matchingDental insuranceEmployee assistance programEmployee discountFlexible spending accountHealth insuranceHealth savings accountLife insurancePaid time offRetirement planVision insuranceSchedule:Monday to FridayAbility to commute/relocate:Greenwich, CT: Reliably commute or planning to relocate before starting work (Preferred)Application Question(s):What is your salary requirement? (responding to this question will accelerate the prescreening process)Education:Bachelor’s (Preferred)Experience:Healthcare Compliance: 2 years (Required)Utilization management: 2 years (Required)Managed Care: 2 years (Required)URAC: 2 years (Required)NCQA standards: 2 years (Required)Quality assurance: 2 years (Preferred)Work Location: One location

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By Richard