Participates in the oversight of health plan business. Review, analyze and collaborate on implementation of new regulatory requirements or health plan policy. Supports efforts to ensure compliance with the laws, regulations, and policies that govern its Medicare and Medicaid business.
Department: Regulatory Affairs
Reports to: Dir, State Regulatory Affairs
- Supports Regulatory Affairs department with regulatory analysis, including the review, summarization and dissemination of key regulatory updates and changes.
- Conducts independent research on assigned projects, collaborates and coordinates with other departments on information needs to ensure process improvement.
- Partner with compliance department to monitor and track all issues up to and including resolution.
- Communicates directly with regulators to resolve health plan complaints.
- Draft responses to queries by regulatory agencies.
- Supports and/or represents health plan at Fair Hearings or other administrative law activities.
- Represents the health plan at federal, state, and local government meetings, workgroups and seminars.
- Coordinates site visits by Federal and State regulators. This function involves developing work plans, collecting deliverables, mock interviews, and site visit facilitation.
- Supports the management of the regulatory communications process. Ensure all regulatory communications/updates are received, summarized, catalogued and disseminated.
- Collaborates with appropriate department leaders to implement new Federal or State health care policies.
- Develops and maintain productive relationships with all levels of management as well as regulators and other relevant external parties.
- Performs other projects as assigned.
- Facilitates and coordinates market review and state approval for all provider and member materials.
- Supports the design and implementation of databases to ensure key departmental processes are documented and tracked.
- Required A High School or GED
- Preferred A Bachelor's Degree in a related field
- Preferred 3 years of experience in a regulatory affairs/ compliance environment or related experience
- Preferred Other Previous State or Federal managed care compliance experience
Licenses and Certifications:
- Intermediate Ability to work independently
- Intermediate Ability to work as part of a team
- Intermediate Ability to work in a matrixed environment
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Knowledge of community, state and federal laws and resources
- Intermediate Demonstrated project management skills
- Intermediate Other Ability to exercise good judgment under pressure
- Intermediate Other Ability to manage a diverse and demanding workload
- Intermediate Other Familiarity with Medicare and Medicaid programs
A license in one of the following is required:
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Access
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft Project