Gateway Health Plan has an excellent opportunity for a Government Affairs Specialist to join their team in Pittsburgh, PA.
This position is responsible for managing the relationships between Gateway Health Plan and Centers for Medicare and Medicaid Services (CMS). The incumbents function as the primary contact with CMS and other Government agencies (i.e. Department of Public Welfare, and any related state or federal agency) for regulatory issues related to Medicare. Interpreting, confirming and clarifying regulations governing HMO practices in order to attain organizational compliance with regulations. Analyzing contractual provisions with CMS and educating Gateway staff regarding Gateway's expected performance under the Medicare contract including Gateway's required and prohibited activities. Acting as a liaison that professionally represents Gateway's business interests on a wide variety of issues in order to accomplish the mission and goals set forth by Gateway's management. Coordinating requests for CMS approval. Designs, delivers and/or documents Medicare-related staff training across the organization in response to any new or revised CMS standards or regulations. Coordinates the receipt and retention of Medicare information related to CMS regulations and policy in a centralized location for staff access.
- The incumbent must serve as the primary point of contact with CMS. Acts as the day-to-day manager of contractual and operational issues, coordinating with internal Plan management staff and CMS to facilitate the identification, definition, and solving of complex business problems and implement corrective action when necessary, thereby ensuring compliance. Contacts include legislators, consumers, special interest groups, advocacy agencies, CMS and other regulatory bodies such as DPW.
- The incumbent must serve as a resource to research and respond to internal management questions. Research includes reviews of various Internet websites including the Centers for Medicare and Medicaid Services (CMS), Federal Register, Pennsylvania Code, Department of Health (DOH), US Census Bureau, Food and Drug Administration (FDA) and the Pennsylvania Power Port, as well as other resources such as CMS contracts and Requests for Proposal (RFPs). Coordinates the receipt of and responses to internally generated inquiries related to CMS regulations and policy in a centralized location for staff access.
- Interprets the information or obtains any clarification that is needed in order to provide appropriate guidance. Continuously monitors regulatory changes, legislative efforts, industry trends, and contract changes and media coverage. Coordinates the receipt and retention of Medicare information related to CMS regulations and policy in a centralized location for staff access. Evaluates the impact on daily business functions, disseminating the information to appropriate GHP management and facilitating any actions necessary for compliance.
- Medicare Implementation process begins with the release of the Request for Proposal (RFP) from CMS, Gateway's technical response, county expansion requests to DOH and implementation planning meetings. Each step of this process involves coordination throughout all levels of Plan management under strict deadlines established by CMS.
- Evaluating submissions for completeness and compliance with CMS contract requirements, logging submissions into a database, tracking submissions to ensure CMS response, notifying the appropriate management of CMS approval, responding to internal and CMS inquiries regarding submissions, and coordination of rejected submissions. Coordinates and submits complaint resolutions to CMS in a timely manner. Tracking of complaint resolutions.
- Designs, delivers and/or documents Medicare-related staff training across the organization in response to any new or revised CMS standards or regulations or required annual trainings.
- Participate and/or Lead Medicare Meetings and Workgroups.
- Other duties as assigned or requested.
- High School diploma or GED
- Three years of experience with the compliance or regulatory process in healthcare or a healthcare-related field.
- 1 year experience with PC.
- Excellent verbal and written communication, analytical, organization and planning skills.
- Skills in diplomacy and tact.
- Bachelor's degree in or equivalent training in healthcare or related field
- 5 years of experience in HMO operations, preferably Medicare or Medicaid HMO operations
- One year experience dealing directly with federal or state agencies.