Compliance Consultant

Job Overview

Compliance Consultant at Blue Cross Blue Shield of Massachusetts. Bring your true colors to blue and help transform healthcare.

• Under the direction of supervisor, analyze and investigate results of monitoring/audits, identify trends, and draft recommendations to systems and procedures that will mitigate risk to the organization.
• Assist with internal clinical compliance initiatives, working closely with applicable teams/leaders, to assure action plans are completed and risk is mitigated in a timely manner. Support the implementation of Clinical Compliance Policies and Procedures. Assist with conducting audits.
• Act as a resource for NCQA and state and federal regulations such as applicable Massachusetts and Rhode Island regulations.
• Meeting planning & facilitation.
• Work with team on process improvements.
• Participate in cross functional meetings; keep project leaders and supervisor informed of key issues, risks, timetables, and project milestones.
• Other responsibilities as identified by the Director.

• Strong attention to detail, problem‑solving and critical thinking skills.
• Strong organization and time management skills including the ability to meet deadlines and manage multiple competing priorities.
• Meeting facilitation skills.
• Excellent interpersonal, verbal and written communications skills.
• Familiarity with NCQA, CMS, FEP and other State and Federal regulatory and accrediting requirements and standards.
• Knowledge of utilization management systems, functions, and processes/workflows.
• Knowledge of NCQA UM accreditation requirements, Massachusetts and Rhode Island utilization review regulations.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint, etc.).
• Knowledge of compliance and quality improvement best practices.
• Experience with auditing is preferred.

• RN or clinical professional degree with active Massachusetts clinical license with 3 years of clinical experience.
• Bachelor’s degree in clinical discipline required, 2 years of utilization management experience required; health insurance experience preferred.
• 1‑2 years of experience working with or familiarity with utilization management regulatory and accreditation standards, such as NCQA, Massachusetts utilization review regulations, Rhode Island utilization review regulations, Federal Employee Plan.

High school degree or equivalent required unless otherwise noted above.

Hingham

Full time

Mid‑Senior level

$84,060.00 - $

This job is also eligible for variable pay. The salary range is the lowest to highest amount we in good faith believe we would pay for this role at the time of this posting. The range may be modified in the future.

We offer a comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well‑being benefits to eligible employees.

We understand that the confidence gap and imposter syndrome can prevent amazing candidates from coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant.

We encourage you to bring us your true colors, your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page.

If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay “in the know” on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our How We Work Page.

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