Job Description
Essential Job Duties - Create and maintain databases and spreadsheets related to regulatory submissions and reporting, licensing, contracts, policies, procedures, laws and regulations.
- Assist in the monitoring and auditing for compliance with privacy and security regulations
- Understand and prioritize timeframes associated with CMS Medicare Advantage (MA) Prescription Drug (PD), federal and state regulatory submissions/reporting calendar, AHP Compliance Toll-Free Hotline, CMS
- Complaint Tracking Module (CTM) and other documents
- Communicate state and federal requirements to internal and external clients
- Review and monitor new and updated laws and regulations, disseminating findings to key stakeholders accordingly.
- Participate on various compliance subcommittees and workgroups
- Perform periodic compliance audits, risk assessments and conducts related ongoing compliance monitoring activities as assigned within the quality work plan, compliance work plan and/or internal audit work plan.
- Assist management with Compliance Committee meetings, agendas and minutes.
- Participate and attend Compliance Committee and other company committees, subcommittees and workgroups, as assigned.
- Prepare analyses/reports based on audit results, including recommendations for corrective action; maintain records of audits and follow-up of corrective actions
- Assist management in developing compliance audit instruments and protocols; assist Management in the development of new and/or revise Medicare Compliance departmental policies and procedures to comply with federal and state regulatory changes
- Under leadership’s guidance, communicate with regulatory agencies to clarify requirements, address reporting and filing issues
- Maintain awareness of industry trends and legislative impact on policies, products and services
- Respond to external requests for information required by the organization for its regulatory filings; respond to inquiries from state and federal regulatory agencies
- Assist in developing, producing and conducting compliance training programs
- Assist affiliated and managed health plans in managing relationships with regulatory agencies and seek to resolve policy issues which may negatively impact service to members
- Other projects and responsibilities as assigned by management
Required Skills - Encourage an atmosphere of optimism, warmth and interest in patients’ personal and health care needs
- Excellent verbal, written, and interpersonal communication skills
- Working knowledge of related federal and state laws and regulations and CMS compliance
- Ability to demonstrate strong understanding of CMS requirements and regulations related to Medicare Advantage and Medicare Part D operations and compliance; has extensive familiarity with relevant resources and is available to provide technical assistance and guidance to business units
- Ability to effectively present highly complex information and respond to questions from groups of managers, clients, customers, and the public
Required Work Experience - Minimum (3) three years’ related experience in compliance, privacy and/or regulatory affairs, legal assistant/paralegal
- Experience in health care industry in related field including understanding of regulatory, contractual, and operational responsibilities of Medicare Advantage plans and Health Maintenance Organizations
- Medicare Compliance, medical claims processing/auditing experience, PBM, and/or pharmacy audit experience preferred
- Project management experience and handling multiple high priority projects with competing deadlines
- Working knowledge of laws and/or regulations in area of compliance; specifically, CMS MA/PD Program, HIPAA, FWA, and state department of insurance laws, regulations and administrative rules
- Strong auditing background preferred
- Qualifying criminal background
Licensing/Certification/Education Requirements - Bachelor’s degree required, preferably in business, finance, accounting, legal, or healthcare
- Certification in Healthcare Compliance (CHC) or other relevant certification(s), or must obtain within the first two (2) years of employment
Job Tags
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