Regulatory and Reporting Specialist

PacificSource Health Plans•Springfield, OR

6d•$44,983 - $71,973•Hybrid

About The Position

Support all aspects of the Grievance and Appeals (G&A) compliance program for Medicare, and Medicaid lines of business. Assume the primary role of interfacing with the Compliance department, Auditors, Vendors and G&A 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 the G&A Department. Conduct internal audits, support external audits, develop policies and procedures, and ensure departmental compliance.

Requirements

Minimum of two years of Grievance and Appeals related health insurance experience required.
High school diploma or equivalent required.
Strong computer skills.
Excellent verbal and business writing skills.
Excellent public relations skills.
Good understanding of Medical Terminology required.
Requires ability to define and prioritize problems and manage workload without direct supervision.

Nice To Haves

Strong preference for experience in auditing or compliance related role.
Bachelor’s degree preferred.

Responsibilities

In partnership with Compliance staff and G&A 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 an internal business rules and regulations.
Be fully informed and ensure compliant processes are in place on all G&A business operations, including but not limited to: Appeals and Grievance processing, OIG status, FWA programs, Helpdesk operations including call monitoring, Communication strategies, Website publications, Claims adjudication, and 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 G&A business operations, publish results and report out to G&A 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 G&A 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 member, G&A and provider communications.
Keeping letters and other member communications up to date with compliance guidance and best practices.
Meet department and company performance and attendance expectations.
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.