Regulatory and Reporting Specialist
About The Position
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.
Requirements
- Minimum of 2 years of compliance-related experience 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.
- Ability to read and comprehend both written and spoken English.
- Communicate clearly and effectively.
Nice To Haves
- Strong preference for health insurance experience.
- Bachelor’s degree preferred.
Responsibilities
- 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 an 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, 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 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.
- Attending 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.
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
