Manuela Heredia Email & Phone Number

Oversight and research of regulatory requirements related to organization operations (compliance, what is required by law, standards or policy);Maintaining up-to-date knowledge of federal and state statutes, regulations, rules and guidelines governing QHPs (Exchange both State and FFE), Medicare and CHP+ lines of business;Management of contract for CHP+, Medicare and Exchange;Audit readiness reviews and reporting requirements which includes oversight, development and implementation of required industry reports;Systematic monitoring and evaluation of various aspects of projects, services, or facility to ensure that standards of quality, compliance and regulatory operations are being met;URAC accreditation – meeting several standards with review and reaccreditation every 3 years. Tracking all required documents and assisting departments in ensuring they are meeting the requirements for URAC;Oversight and implementation of organization required training as specified in regulations, and related to URAC accreditation and compliance;Oversight of quality improvement, a systematic, formal approach to the analysis of practice performance and efforts to improve performance;Oversight, development and implementation of the Quality Management Program Committee;Implementation and direction of Quality Improvement Projects, including establish measurable goals, designing and implements strategies to improve performance. This includes QIPs and PIPs, completion of HEDIS (QRS Ratings), CAHPS and QHP Enrollee Experience Surveys;Inter-departmental collaboration to promote quality achievement and performance improvement throughout the organization;Provide recommendations to improve internal processes, customer satisfaction and performance measures;Oversight, development and implementation of the annual QHP Certification Process for all current and/or new states. Submission in both HIOS and SERFF;Working closely with CMS and CCIIO in coordinating submissions related to Federal government and ACA requirements;Collaboration with CMS and Divisions of Insurance to obtain data changes and specific requirements related to reports and filings.Working closely with legal to ensure that regulatory requirements are pertinent and required of the organization.Maintain and revise Compliance Program, including direction and management of Compliance HotlineMonitor and, as necessary, coordinate compliance activities of other department to remain abreast of the status of all compliance activities and to identify trends.Ensure proper reporting of potential HIPAA violations