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Overview

Position Overview:

Looking for a subject matter expert in the healthcare regulatory & compliance space, with acumen and passion for leveraging innovative technology to solve critical needs in healthcare. This individual will report to the Chief Medical Officer of Healthedge (HE) and ensure that our clinical suite of products (GuidingCare & Wellframe) support our health plan customers in achieving and maintaining compliance with the regulatory bodies that govern them: NCQA (National Committee for Quality Assurance), CMS ( Centers for Medicare & Medicaid Services) , URAC (Utilization Review Accreditation Commission) and other State regulatory bodies. The ideal candidate will have a strong understanding of healthcare compliance requirements across multiple regulatory bodies, as well as a deep knowledge of clinical software programs, and the ability to discern the role of the vendor in regulatory compliance.

About Wellframe:

With Wellframe, we reimagine healthcare relationships through a new approach that uses high-tech to deliver the high-touch support people need, when and where they need it. We call it Digital Health Management. Our comprehensive suite of Digital Health Management solutions for care management, advocacy, and navigation help organizations forge more meaningful connections with members, across their healthcare journey. Wellframe was founded to counter a pressing industry problem: the healthcare system has struggled to find ways to support people in between care settings, at scale. We believe health plans are in the best position to advocate for their members as they navigate their health and care, but know that technology alone can’t help us achieve this ambition. That’s why our team of physicians, clinicians, public health experts, data scientists, engineers, and healthcare industry experts ensure our patented technology works in service of the person-to-person connections that make healthcare work best. The complete suite of solutions from HealthEdge delivers a digital foundation for payers specifically designed to fuel a digital transformation, reduce costs, and improve both clinical outcomes and the member experience.

Your Impact:

• Proactively monitor and interpret NCQA, URAC, CMS and key state regulations in accordance with anticipated updates or revisions, providing expert impacts relevant to our customers and our software.
• Partner with enterprise legal & compliance team to identify and document clinical regulations relevant to our HealthEdge products
• Collaborate with Product & Marketing stakeholders to establish clinical product positioning as it pertains to regulatory compliance (i.e. what is/should be a care management system & member engagement application’s role in the context of regulatory requirements – how health plan customers should perceive our digital products & how they advance their alignment/compliance with regulatory requirements)
• Identify any areas of non-compliance in the applications, services, and processes & analyze potential risks to develop action plans when gaps are identified
• Develop a compliance scorecard; monitor and improve the adherence of the product portfolio to the compliance scorecard.
• Research and track trends and developments in governmental regulations related to compliance to ensure that HealthEdge invests in an effective roadmap to maintain compliance for our customers.
• Act as the subject matter expert and advisor on relevant legislation and regulations that apply to compliance and how this will impact our products & our customers.
• Ensure that compliance requirements are correctly and effectively communicated to all stakeholders; create periodic regulation update briefs for internal use.
• Communicate changes in regulations to customers in a clear and concise manner via multiple methods: Conduct User Groups; 1:1 Sessions with key customers; Delivering Blogs; Respond to questions via email from internal and external customers.
• Ensure workflows, policies, and procedures are implemented and maintained for relevant regulatory and accreditation requirements
• Develop business cases and requirements for new products and enhancements that advance organizational alignment with regulatory requirements and credibility in the market
• Develops and leads regulatory survey readiness planning process for relevant accreditations and certifications

What You Bring:

• Bachelor’s degree in a healthcare related field
• Legal and/or Clinical graduate-level or professional experience preferred
• Experience in HEDIS data and analytics are preferred
• Extensive experience in the healthcare industry, particularly in the Payer space, with a perspective on how health plan operations impact willingness to adopt digital transformation and innovation
• 7+ years' experience with healthcare compliance/regulations – Medicare, Medicaid, federal and state requirements
• Advanced knowledge and in-depth understanding of NCQA, HEDIS, CMS, and State processing requirements
• Demonstrated ability to define & articulate business solutions to compliance issues; and to educate and achieve alignment with internal and external audiences
• Experience working with regulatory requirements in a software product development environment
• Familiarity with CMS reporting, audit requirements and audit procedures.
• Demonstrated attention to detail
• Strong interpersonal, communication, organizational and coordination skills
• The ability to work independently, as well as part of a team or as team leader
• Strong analytical and storytelling capabilities

HealthEdge commits to building an environment and culture that supports the diverse representation of our teams. We aspire to have an inclusive workplace. We aspire to be a place where all employees have the opportunity to belong, make an impact and deliver excellent software and services to our customers.

Geographic Responsibility: While HealthEdge is located in Burlington, MA you may live anywhere in the US

Type of Employment: Full-time, permanent

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
• Work across multiple time zones in a hybrid or remote work environment.
• Long periods of time sitting and/or standing in front of a computer using video technology.
• May require travel dependent on company needs.

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check.

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.