This position is accountable for facilitating activities involved in the implementation of state and federal health mandates and other administrative regulatory requirements. Activities involved include the development of project plans, creating and facilitating workgroups to implement health mandates and other regulatory requirements, creating task/action plans, maintaining documentation to support compliance and development of communications for compliance requirements. Activities also include communication with federal regulators for purposes of operational or policy guidance, resolution of compliance issues and growth and maintenance of favorable regulatory relationships to meet the company's business needs. This position is also responsible for acting as a representative of the company with other organizations and/or vendors related to government programs and for identifying and reporting potential risk areas to the Director and Mandate Implementation Team appropriate individuals.- Manages compliance activities for a division by facilitating the development of project plans and the implementation of state and federal health mandates and other administrative regulatory requirements across all divisions.
- Coordinates activities of the Mandate Implementation Team to accomplish compliance with federal and state health mandates.
- Assembles and manages process improvement teams resulting from product management activities.
- Assembles and manages process improvement teams resulting from Mandate Implementation Process and other state and federal regulatory matters.
- Identifies and reports potential risk areas to the Director and Mandate Implementation Team appropriate individuals.
- Ensures that task/action plans to address noncompliance and product improvement opportunities are developed and implemented.
- Initiates the development of ideas and actions for product improvement activities, especially those focusing on revenue enhancement or expense reduction in the area of government programs. When appropriate, leads improvement activity efforts.
- Acts as a representative of the company with other organizations and/or vendors related to government programs.
- Develops communications for compliance requirements based on a variety of sources.
- Develops and maintains documentation to support compliance with health mandates and the major legal and business decisions made in the compliance efforts.
- Works with the audit department and others on the end to end audits for mandate implementation.
- Keeps abreast of potential changes to state and federal health mandate legislation that impacts the Enterprise.
- Acts as a liaison for tracking and responding to appeals and complaints for the Executive office as well as the Department of Banking and Insurance, the Centers for Medicare and Medicaid Services and member advocacy groups pertaining to Government programs.
- Researches, writes and updates policies and workflows for compliance with state and federal regulatory matters.
- Monitors, analyzes and prepares reports on compliance activities and other topics as needed.
- Demonstrate knowledge, understanding and conform to laws, regulations and policies that pertain to the organizational units business.
- Requires a Bachelor's degree from an accredited college or university.
- Requires a minimum of five years experience in the health insurance industry including experience with compliance mandates and interacting with government agencies.
- Requires prior project management experience.
Skills and Abilities:
- Requires knowledge of the state and federal regulatory environment in the health insurance industry.
- Requires experience with compliance issues in a health insurance environment.
- Prefer contract knowledge.
- Requires the ability to utilize a personal computer and applicable software.
- Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals.
- Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
- Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment.
- Proven ability to exercise sound judgment and strong problem solving skills.
- Proven ability to ask probing questions and obtain thorough and relevant information.
- Must be client service focused with effective ability to empathize.
- Must be detail oriented with strong organizational and data processing skills. Proven ability to follow detailed instructions is essential, along with excellent math skills.
- Proven analytical, research and problem solving skills a must.
- Must demonstrate the ability to learn quickly and apply learning to new situations. Must exhibit flexibility to change as appropriate.
- Demonstrated ability to make decisions with little need for direction and to function effectively as a team-oriented, self-starter working across cross-functional lines.
- Must have strong entrepreneurial business development, negotiation, relationship building, and networking skills.
Horizon Blue Cross Blue Shield of New Jersey - 19 months ago