Regulatory Compliance Associate

Horizon Blue Cross Blue Shield of New Jersey•Newark, NJ

1d•Onsite

About The Position

The Regulatory Compliance Associate is responsible for the identification and communication of new, revised, and pending federal and state laws, regulations, and standards relevant to a Horizon Lines of Business (LOB). This position administers and coordinates the functions associated with compliance and regulatory guidelines related to each market and will develop and maintain standard operating policies and procedures, compliance reporting and dashboards, and execute the annual Compliance workplan. This position will work with business to ensure compliance with relevant agencies including but not limited to: Centers for Medicare & Medicaid Services (CMS), Division of Medical Assistance and Health Services (DMAHS), Get Covered New Jersey and The New Jersey Department of Banking and Insurance (DOBI). Regulatory Compliance Associates collaborate with internal divisions to foster a compliant culture and ensure regulatory compliant materials and activities.

Requirements

High School Diploma/GED required.
Bachelor degree preferred or relevant experience in lieu of degree.
Requires a minimum of five (5) years of relevant compliance experience in a healthcare or managed care environment.
Requires a minimum of three (3) years experience in the interpretation and application of federal and state regulations, policies and procedures, and ethical principles related to healthcare compliance.
Knowledge of the sources of legal and regulatory requirements relevant to state and federal requirements.
Medicaid: Knowledge of the Federal and State regulatory environment in the health insurance industry, with emphasis on Medicaid and NJFamilyCare, Managed Long-Term Services and Supports, the New Jersey False Claims Act, Fraud, Waste and Abuse, Anti-Kickback law and State Medicaid requirements.
Commercial: Knowledge of the Federal and State regulatory environment in the health insurance industry, with emphasis on state and federal mandates, health insurance exchanges, qualified health plans, and the Affordable Care Act. Understanding of compliance issues and healthcare risk areas applicable to Commercial insurance.
Medicare: Knowledge of state and federal laws and regulations, including CMS, DOBI and DMAHS requirements. Knowledge of CMS regulations, including Medicare Marketing guidelines.
Excellent at organizing, managing, and handling competing projects with a proven ability to meet tight deadlines in a fast-paced environment.
Skilled at managing a high volume of work with changing priorities and frequent interruptions while maintaining the ability to work cooperatively with a positive attitude.
Written and oral communication.
Facilitation, active listening, and presentation skills.
Critical thinking skills and the ability to apply an analytical approach to regulatory research and issue remediation.
Persuasion/negotiation and interpersonal relationship skills and the ability to effectively interact and collaborate with individuals at all levels within the organization.
Problem solving acumen.
Ability to identify potential noncompliance issues, obtain information to clarify and describe issue, exercise sound decision-making, resolve problems using appropriate risk treatment, and leverage appropriate escalation pathways.
High degree of discretion in dealing with the confidentiality of all compliance-related issues.

Nice To Haves

Certified Compliance & Ethics Professional Certification (CCEP) - Compliance Certification Board
Certified in Healthcare Compliance (CHC) - Compliance Certification Board
Leadership Professional in Ethics & Compliance (LPEC) - Ethics and Compliance Institute

Responsibilities

Maintain knowledge of all relevant legislative and regulatory health plan requirements and monitor information sources for changes in regulatory compliance program requirements for Horizon’s LOBs.
Analyze information and determine what is informational versus change affecting organizational processes.
Review, interpret, summarize and communicate new and revised requirements to the business unit personnel using multiple distribution methods.
Provide plain language compliance guidance and direction to operationalize regulatory compliance requirements and support implementation of changes stemming from new or revised State and Federal requirements.
Oversee compliance with new, revised, and pending regulatory requirements through the Requirements Database, and collect and evaluate evidence of compliance submissions from business unit personnel.
Support and actively participate in annual team functions including monitoring, ongoing risk assessment, audit readiness activities, external audit coordination, executing the compliance workplan, and other divisional priorities related to risk mitigation.
Gather relevant data and Key Performance Indicators for compliance reports and dashboards, and prepare reports based on established reporting metrics for the group.
Independently investigate areas of non-compliance, and act on matters by designing and coordinating internal investigations and resulting corrective action plans with all departments.
Identify potential non-compliance vulnerabilities and make practical business recommendations to correct non-compliance or improve insufficient processes.
Monitor business units’ self-monitoring results to ensure that current procedures satisfy regulatory requirements and are sufficient to detect future instances of non-compliance.
Assist with the development of compliance policies, control processes, self-monitoring, and self-auditing tools that promote maintaining compliant business processes.
Develop and update Standard Operating Policies and Procedures (SOP) for review processes and compliance. Educate stakeholders on these SOPs.
Develop collaborative relationships with regulators.
Monitor compliance related commitments made to regulatory agencies governing Horizon’s LOBs, and review and maintain submissions, reports, and filings to regulators.
Actively participates in the annual product implementation, including providing guidance on and facilitating review and approval of all materials related to product implementation (i.e. annual notices of change, evidence of coverage documents, formulary and provider related material and model operational letters).
Serve as a subject matter expert on the CMS (Center for Medicare & Medicaid Services) Medicare Marketing Guidelines (MMG) for Horizon's Medicare products.
Establish and maintain a comprehensive understanding of all CMS and State requirements related to Medicare Advantage, Medicare Part D and Medicaid requirements, for the special needs plan, with respect to marketing and related materials.
Develop and maintain tools to facilitate and report on the internal review of materials (e.g. internal CMS Submission Database; SharePoint site functionality) consistent with evolving CMS and DMAHS marketing guidelines.