Under the supervision of the Director of Medical Management Business Process Monitoring, the Senior Business Process Monitoring Analyst will be directly responsible for monitoring work plan member level charts, transactions and data driven line items. The role requires the candidate to carefully audit member related transactions, review plans of care and provide constructive risk assessment feedback to ensure CMS and DOH audit readiness and all applicable regulatory requirements are met. The Senior Business Process Monitoring Analyst must have the ability to approach the work-related items efficiently and strategically to provide accurate and actionable feedback post audit monitoring and risk analysis activity, both verbally and in writing. This candidate would contribute to monitoring, reporting own work plan data tracking sheet to account for productivity and accountability. This candidate will also be responsible for ad hoc projects aimed at ensuring the organization’s overall compliance. Senior Business Process Monitoring Analyst maintains a collaborative relationship with allied departments within the company, working closely with Regulatory Affairs and Compliance on regulatory changes impacting MetroPlusHealth and monitor specific operational areas to improve operational efficiencies.

The Senior Business Process Monitoring Analyst is also responsible for supporting delegation oversight. They work closely with the MetroPlusHealth departmental subject matter experts to ensure the delegates comply with regulatory and contractual requirements. Based on their findings, the Senior Business Process Monitoring Analyst issues corrective action plans to satisfy regulatory and plan requirements.

• Reviews various medical management area program descriptions, program evaluations and work plans for compliance with regulatory and contractual requirements. Proposes revisions to bring areas into compliance with requirements, if necessary.
• Creates, reviews, and submits internal tracking mechanisms for productivity and accountability purposes.
• Assists in evaluating existing audit tools and propose revisions that aligns with up-to-date regulatory standards.
• Participates in business area on-site and/or desk-top audits and/or schedules ad hoc on-site meetings as required, to address specific compliance issues or support implementation of new policies and regulations.
• Provides support to business areas, upon identification of non-compliance, by conducting a root cause analysis and corrective actions, including guidance on methodology, identification of relevant regulatory requirements and any regulatory compliance context, and compliance review.
• Plays a critical role in driving the progress for corrective actions.
• Participates in joint operating committee meetings with other MetroPlusHealth business owners and delegated vendors.
• Participates in meetings with delegates to provide performance metrics feedback.
• Other duties as assigned or requested.

• Bachelor’s Degree; and
• 3-5 years’ experience in a Managed Care setting; or
• A satisfactory equivalent combination of education, training, and experience.
• Experience with regulatory requirements specifically CMS and NYS DOH.
• LPN or RN preferred but not required

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication
• Project management skills with ability to handle multiple projects with various priorities and deadlines
• Ability to work independently in a fast-paced environment with changing priorities
• Strong interpersonal and human relations skills and ability to establish and maintain strong positive working relationships
• Strong written and verbal communication and presentation skills
• Ability to learn new software to conduct documents and file review

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