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Director Managed Care Compliance and Quality in Jacksonville, FL at One Call

Date Posted: 5/30/2018

Job Snapshot

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Job Description

Director Managed Care Compliance and Quality

The Director Managed Care Compliance and Quality will lead in the development and oversight of the company's Managed Care (Group Health) compliance and quality programs including Quality Plans, compliance, contracting, complaints and grievances and fraud, waste and abuse. Provide the company with accurate, complete, up-to-date and relevant information regarding the legal and regulatory requirements governing One Call Care Management's group health operations, and assist with the implementation of policies, systems and processes to ensure compliance with such requirements.


  • Lead the Company's Group Heath Compliance Program.
  • Develop and lead all Group Health Quality Plans.
  • Facilitate, provide input and oversee all Group Health contracting activities
  • Act as a liaison between the Company and various state and federal legislative/regulatory bodies.
  • Provide the Company with accurate, complete, up-to-date and relevant information regarding the legal and regulatory requirements governing Group Health operations, and any changes to such requirements.
  • Advise the Company of new or emerging regulatory issues that may affect the Company's operations.
  • Consult with business units on the impact of legal and regulatory requirements on new business strategies, projects, systems and processes.
  • Assist operational units to identify and implement necessary changes to ensure compliance with legal requirements. Monitor or manage the implementation of such changes, as needed.
  • Oversee and report on the results of compliance-related audits.
  • Ensure that all Associates receive appropriate Compliance-related training, including New Hire training, annual Compliance Training, and other programs as needed.
  • Manage and direct special compliance-related projects, as needed.
  • Research and respond to compliance-related inquiries from external and internal customers.
  • Perform other duties and tasks as assigned.
  • Travel out-of-state as required.

Bachelor's degree (B.A. or B.S.) with experience in the compliance field, required; J.D. or paralegal certificate and experience preferred . Supervisory or management experience is preferred.

  • 5+ years' experience with Medicaid/Medicare in compliance, contracting and/or quality programs
  • Previous leadership/management experience in a compliance-related position
  • Knowledge/experience in evaluating and interpreting regulations governing health care.
  • Experience with Managed Care contracts and RFP's
  • Excellent verbal, grammar and writing skills.
  • Excellent legal research skills.
  • Proficiency with Excel, Word, Outlook and PowerPoint required.
  • Ability to organize workflow and juggle multiple tasks.
  • Excellent communication and analytical skills
  • Must be able to identify complex problems and review related information to develop and evaluate options and implement solutions.

  • For roles located in office or home settings; this job is primarily sedentary and may involve repetitive motions; the employee is regularly required to sit, use hands and fingers, speak, and hear.
  • For roles located in the field; this job is primarily active; the employee is regularly mobile and must be able to utilize transportation (such as driving), sit, use hands and fingers, speak, and hear.
  • The employee is occasionally required to stand, walk, and lift objects (up to 10lbs weight; up to 4 ft. height).
  • Specific vision abilities required by this job include ability to see things from a close distance and ability to adjust focus.
  • The work environment utilizes florescent lighting; noise level is moderate.
  • The emotional demand of the job may cause undue stress from, but not limited to, moderate/heavy workload.
  • Reasonable accommodations will be individually assessed and possibly made to enable individuals with disabilities to perform the essential functions of the position.
  • Please be advised the job description is subject to change at any time.


Director Compliance Administration

Advanced managerial role - manages and coordinates direct and indirect teams with enterprise reach and impact within multiple components of the program and has responsibility for results, including costs, methods and staffing. Results are both internally and externally focused and directly affect the program or are externally focused and affect customers, partners, stakeholders and/or employees at the enterprise level across all business lines. Establishes operational objectives and work plans and delegates assignments to subordinates as well as coordinates efforts of employees that are not in their direct control. Objectives are often managed independently with refinement by senior management. This role is involved in developing, modifying and executing company policies that affect the entire enterprise. Works on issues where analysis of situations or data requires an in-depth knowledge of organization objectives, implements strategic policies when selecting methods, techniques, and evaluation criteria for obtaining results, and establishes and ensures adherence to budgets, schedules, work plans, and performance requirements. . Oversees the development and implementation of the compliance program policy, and standards as well as addressing other required regulatory policies . Regularly interacts with senior management or executive levels on matters concerning several functional areas and/or customers. Requires the ability to change the thinking of, or gain acceptance from others in sensitive situations without damage to the relationship. This level requires the ability to communicate with all levels of management. Typically requires a minimum of 8 to 10 years management experience.