Regulatory Compliance Specialist / Job Req 788792522

PRINCIPAL RESPONSIBILITIES:

Under the direction of the Supervisor, Regulatory Affairs & Compliance, the Regulatory Compliance Specialist supports the compliance program by coordinating implementation of new and revised healthcare rules and requirements as are communicated by state and federal agencies.

Principal responsibilities include:

• Read, review and summarize prospective, new and revised rules and healthcare policy from local, state and federal agencies, including but not limited to, the Department of Managed Health Care (DMHC), the Department of Health Care Services (DHCS), and Centers for Medicare & Medicaid Services (CMS).
• Coordinate with internal departments to gather data and information for regulatory submissions, including Medicare Advantage plan bids and formulary submissions
• Schedule and lead meetings with stakeholders to review analysis, discuss key points, next steps, and potential issues affecting implementation, including Medicare Advantage and Part D compliance requirements.
• Documents all actions taken by stakeholders to maintain a clear written record of the chronology of implementation for tracking and transparency.
• Assist with the completion of CMS, DMHC and DHCS submission, amendments and material modifications related to all policy preparation, implementation and execution, including Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents for Medicare Advantage plans.
• Assist with internal information gathering as may be required during audits and other requests from state and federal agencies, including CMS program audits.
• Participate in and represent the Alliance at state agency and professional association meetings, trainings, conferences and webinars related to new regulatory mandates, regulatory updates, new member benefits and changes to existing member benefits, with a focus on Medicare Advantage and Part D programs.
• Participate in and represent the Compliance Department on internal committees and work groups related to prospective, new or revised legislation and policy work, including Medicare Advantage and Part D policy changes.
• Assist in coordinating state and federal audit visits and complete responses, including Medicare Advantage and Part D program audits.
• Assist in the implementation of audit processes to ensure compliance with federal and state statutes and regulations and program guidance, including Medicare Advantage and Part D requirements.
• Research questions from staff regarding regulatory compliance related to all products and business.
• Maintain knowledge of business products and related Alliance policies and procedures and alert the compliance staff of non-compliance risks, with emphasis on Medicare Advantage and Part D products.
• Distributes the Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS) All Plan Letters (APL), CMS Guidance and other regulatory policy guidance to internal stakeholders in a timely manner. This includes Medicare Advantage and Part D memoranda, guidance, and regulatory updates.
• Complete other special projects and duties as assigned, to include Medicare-related initiatives.

ESSENTIAL FUNCTIONS OF THE JOB:

• Communicating effectively and efficiently internally and externally.
• Writing, reporting, researching, administration, and analysis.
• Developing verbal presentations.
• Leading and participating in internal and external committees and meetings.
• Complying with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS:

• Constant and close visual work at desk or on a computer.
• Constant sitting and working at desk.
• Constant data entry using keyboard and/or mouse.
• Frequent use of telephone headset.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and various other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.

Number of Employees Supervised: 0

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• Bachelor of Arts or Bachelor of Science degree required. Focus in related field, preferred.
• In lieu of degree, equivalent education and/or experience may be considered
• Familiarity with Medicaid (Medi-Cal), Medicare and other publicly funded programs.
• Familiarity with CMS, DHCS, DMHC rules and regulations.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• One-to-Three-year related experience in healthcare preferably in a managed care setting.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Experience with CMS reporting compliance for clients (CDAG/ODAG/ODR/CDE) preferred.
• Familiarity with Medicare Marketing Guidelines and materials development process, a plus.
• Understanding of Medicare risk adjustment methodologies and processes a plus.
• Understanding of federal and state regulatory bodies and processes.
• Proficiency in correct English usage, grammar, and punctuation.
• Ability to communicate effectively, both verbally and in writing.
• Exemplary interpersonal skills including ability to collaborate effectively as part of a team across organizational structure is a must.
• Ability to ability to think critically, make informed decisions and work independently with minimal supervision.
• Excellent organizational skills and orientation to detail.
• Proven ability to prioritize and manage multiple projects simultaneously and meet deadlines.
• Experience in use of computer system software such as MS Word, Excel, Access, Outlook, SharePoint, and PowerPoint.
• Familiarity with SmartSheet and Team Dynamics (TDX), a plus.
• Familiarity with HPMS, DMHC E-filing/Timely Access Portal and DHCS Submission Processes, a plus.

SALARY RANGE: $83,241.60 - $124,862.40 Annually

The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.