[Hiring] Regulatory and Reporting Specialist @PacificSource Health Plans

Role Description

Support all aspects of our Appeals and Grievance (A&G), Care Management (CM), and Utilization Management (UM) compliance program for Medicare, and Medicaid lines of business. Assume the primary role of interfacing with the Compliance department, Auditors, Vendors and staff for purposes of monitoring and ensuring compliant operations. Interface with the Compliance Department and Fraud, Waste and Abuse teams to evaluate and address fraudulent activities impacting these departments. Conduct internal audits, support external audits, develop policies and procedures, and ensure departmental compliance.

• In partnership with Compliance staff and leadership, develop auditing and monitoring plans to assess compliance with all State, Federal and internal business rules and regulations.
• Serve as an inter-departmental liaison for compliance and FWA activities.
• Inform all business operations and workflow decisions to ensure that programs are compliant with State, Federal and internal business rules and regulations.
• Be fully informed and ensure compliant processes are in place on all business operations, including but not limited to:
  • Business processes
  • OIG status
  • FWA programs
  • Helpdesk operations including call monitoring
  • Communication strategies
  • Website publications
  • Claims adjudication
  • All vendor managed programs
• Maintain a current working knowledge of all applicable Medicare, and Medicaid rules and regulations including assessment, impact report and training on any new rules or regulations to all impacted departments.
• Conduct frequent monitoring activities of all business operations, publish results and report out to Leadership, Compliance Department, quality committees and other PacificSource leadership teams as applicable.
• Respond to all compliance related inquiries from internal Compliance Department Staff and external Auditors in a timely, professional and accurate manner to ensure minimal organizational and operational impact.
• Work collaboratively with leadership to produce and monitor department policies and procedures as applicable and ensure their regular maintenance to reflect new practices and guidance.
• Provide interpretation, training, and implementation of Medicare, and Medicaid regulations and communicate them appropriately with respective departments and teams.
• Attend weekly meetings; review and approve external communications; and monitor operational performance reports.
• Support ongoing communication efforts. Maintaining compliant members, departments, and provider communications. Keeping letters and other member communications up to date with compliance guidance and best practices.

Qualifications

• Minimum of 2 years of compliance-related experience required. Strong preference for health insurance experience.
• High school diploma or equivalent required. Bachelor’s degree preferred.
• Strong computer skills.
• Excellent verbal and business writing skills.
• Excellent public relations skills.
• Good understanding of Medical Terminology required.
• Ability to define and prioritize problems and manage workload without direct supervision.

Requirements

• Adaptability
• Building Customer Loyalty
• Building Strategic Work Relationships
• Building Trust
• Continuous Improvement
• Contributing to Team Success
• Planning and Organizing
• Work Standards

Benefits

• Base Range: $44,982.98 - $71,972.77
• Compensation Disclaimer: The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity.

Physical Requirements

• Stoop and bend.
• Sit and/or stand for extended periods of time while performing core job functions.
• Repetitive motions to include typing, sorting and filing.
• Light lifting and carrying of files and business materials.
• Ability to read and comprehend both written and spoken English.
• Communicate clearly and effectively.

Disclaimer

This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.