[Remote] Specialist III - Healthcare Business Support

Note: The job is a remote job and is open to candidates in USA. Florida Blue is hiring a Specialist III to support its Utilization Management department. The role focuses on compliance with CMS requirements and NCQA accreditation standards, while providing broader business, policy, audit, project, and stakeholder support.

Responsibilities

• Serve as a liaison between internal clients and functional departments; help clients achieve their objectives by serving as a resource in the interpretation, application and compliance with internal and external laws, regulations, policies, procedures, standards and practices
• Identify risks, evaluate controls and prepare findings and recommendations. Implement compliance programs to prevent illegal, unethical or improper business practices
• Monitor and evaluate the effectiveness of solutions, policies, practices and processes to ensure continuous improvement, good client relations and adherence to business requirements. Recommend improvements to achieve and deliver high quality, value-added services
• Develop, implement, administer and revise policies, procedures and programs that meet business needs; assist and/or lead program development and enhancements
• Research, analyze, maintain, modify, validate and prepare data, information and content used in making business decisions. Present findings and articulate results
• Produce, edit and distribute a variety of business documents such as reports, proposals, policies, procedures, audit results, issue papers, marketing materials, newsletters, brochures, etc
• Create, present and/or facilitate meetings, webinars, conference calls, training programs, education sessions, certifications, etc. for a variety of internal and external audiences
• Represent assigned function at external hearings, mediations, audits, meetings, etc
• Participate on or lead large, complex departmental and/or divisional projects. Plan, organize, monitor and control projects to ensure the effective use of resources and adherence to project management standards and reporting requirements
• Participate on Company workgroups and initiatives
• Develop and build internal and external partnerships to improve communication, coordination, collaboration and effective working relationships within own department, across the Company and outside of the Company
• Mentor and coach less experienced coworkers on the technical and interpersonal skills needed for effective job performance
• Provide support to Florida Blue's Utilization Management (UM) department by ensuring adherence to Centers for Medicare and Medicaid Services (CMS) requirements and National Quality Care Assessment (NCQA) accreditation standards

Skills

• 5+ years related work experience
• Related Bachelor's degree or additional related equivalent work experience
• Demonstrated experience with audits that the organization's programs are consistently administered in compliance with organizational policies and procedures, contractual obligations, rulings, laws and government regulations
• Proven experience leading large, complex departmental and/or divisional projects. Plan, organize, monitor and control projects to ensure the effective use of resources and adherence to project management standards and reporting requirements
• Ability to Identify risks, evaluate controls and prepare findings and recommendations. Implement compliance programs to prevent illegal, unethical or improper business practices
• Knowledge of Medicare Advantage, Commercial, and ACA plan-specific UM compliance requirements (CMS, NCQA, FL Statutes)
• FL active and unrestricted RN license or compact RN license
• Experience with Florida Blue UM processes and procedures
• Experience with NCQA accreditation standards and survey preparation
• Demonstrated experience with compliance documentation, policy implementation, and periodic compliance evaluation/quality audit methodologies
• Proven ability to align departmental practices with enterprise compliance standard

Benefits

• Medical, dental, vision, life and global travel health insurance (benefits may vary based on the state in which work is performed)
• Income protection benefits: life insurance, short- and long-term disability programs (benefits may vary based on the state in which work is performed)
• Leave programs to support personal circumstances (benefits may vary based on the state in which work is performed)
• Retirement Savings Plan including employer match (benefits may vary based on the state in which work is performed)
• Paid time off, volunteer time off, 10 holidays and 2 well-being days (benefits may vary based on the state in which work is performed)
• Additional voluntary benefits available (benefits may vary based on the state in which work is performed)
• A comprehensive wellness program (benefits may vary based on the state in which work is performed)
• Opportunities for incentive or commission compensation
• Hybrid work arrangement combining flexibility with office engagement; team schedules are determined based on role requirements and business needs

Company Overview

Company H1B Sponsorship