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Director of Product Compliance, Appeals & Grievances

Role Overview

MedHOK is a Software as a Service (SaaS) platform used by health plans to perform operational functions including processing grievances, appeals, authorizations, and care management in compliance with Medicare, Medicaid, and other state and federal regulations.

The Director of Product Compliance, Appeals and Grievances will provide regulatory compliance and business subject matter expertise to maintain and enhance platform compliance.   This position manages and implements programs, policies, and practices to ensure compliance with Medicare, Medicaid, and other federal and state regulatory requirements.   The ideal candidate has health plan experience and is passionate about compliance and product innovation.

Essential Duties and Responsibilities

  • Ensure the MedHOK platform is compliant with applicable Appeals and Grievance requirements
  • Educate and communicate both verbally and in writing any new or changed regulations to the leadership and/or impacted staff, as well as current and potential clients
  • Ensure Regulatory and Audit Universe reports are current and accurate
  • Facilitate and/or perform mock audits using ODAG audit reports and assist clients with CMS audit preparation
  • Ensure product content, workflow and SLAs meet client, regulatory and accreditation requirements
  • Conduct platform testing as part of the software development life cycle to ensure compliance prior to release
  • Identify potential areas of compliance vulnerability and risk, develop and implement corrective action plans
  • Maintain current subject matter expertise in relevant regulatory requirements
  • Able to adapt to competing demands, take on new responsibilities, and adjust plans to meet changing priorities

Requirements

  • 5 years managed care experience (Compliance, Appeals and Grievances) with CMS guideline implementation and oversight in a healthcare setting
  • Auditing and Corrective Action Plan/Risk Mitigation Experience required
  • Direct Customer facing experience
  • Formal Presentation experience
  • Demonstrated proficiency in computer skills to include Word, Power Point and Excel
  • Bachelor’s Degree/Associates Degree or relevant work experience

Other Skills/Abilities

  • Experience identifying key metrics and cross walking regulatory requirements
  • Excellent interpersonal and communication skills (written and oral)
  • Strong organization and prioritization skills with ability to handle multiple tasks
  • Results oriented
  • Exhibits honesty and integrity
  • Self-motivated, Self-directed
  • Critical thinker
  • Analytical skills
  • Tact and positive demeanor
  • Flexible
  • Dedication to a high degree of customer service
  • Conflict resolution/ problem solving skills
  • Team player/team builder/coach

Location

Position based at the Tampa, Florida, office.  Only local candidates or those planning on relocating will be considered

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