What are the responsibilities and job description for the Regulatory and Reporting Specialist position at PacificSource Health Plans?
Looking for a way to make an impact and help people?
Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
Support all aspects of the Grievance and Appeals (G&A) compliance program for Medicare, and Medicaid lines of business. Assume the primary role of interfacing with the Compliance department, Auditors, Vendors and G&A staff for purposes of monitoring and ensuring compliant operations. Interface with the Compliance Department and Fraud, Waste and Abuse teams to evaluate and address fraudulent activities impacting the G&A Department. Conduct internal audits, support external audits, develop policies and procedures, and ensure departmental compliance.
Essential Responsibilities:
- In partnership with Compliance staff and G&A leadership, develop auditing and monitoring plans to assess compliance with all State, Federal and internal business rules and regulations.
- Serve as an inter-departmental liaison for compliance and FWA activities.
- Inform all business operations and workflow decisions to ensure that programs are compliant with State, Federal an internal business rules and regulations.
- Be fully informed and ensure compliant processes are in place on all G&A business operations, including but not limited to: Appeals and Grievance processing, OIG status, FWA programs, Helpdesk operations including call monitoring, Communication strategies, Website publications, Claims adjudication, and all vendor managed programs.
- Maintain a current working knowledge of all applicable Medicare, and Medicaid rules and regulations including assessment, impact report and training on any new rules or regulations to all impacted departments.
- Conduct frequent monitoring activities of all G&A business operations, publish results and report out to G&A Leadership, Compliance Department, quality committees and other PacificSource leadership teams as applicable.
- Respond to all compliance related inquiries from internal Compliance Department Staff and external Auditors in a timely, professional and accurate manner to ensure minimal organizational and operational impact.
- Work collaboratively with G&A leadership to produce and monitor department policies and procedures as applicable and ensure their regular maintenance to reflect new practices and guidance.
- Provide interpretation, training, and implementation of Medicare, and Medicaid regulations and communicate them appropriately with respective departments and teams.
- Attend weekly meetings; review and approve external communications; and monitor operational performance reports.
- Support ongoing communication efforts. Maintaining compliant member, G&A and provider communications. Keeping letters and other member communications up to date with compliance guidance and best practices.
Supporting Responsibilities:
- Meet department and company performance and attendance expectations.
- Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
- Perform other duties as assigned.
Work Experience: Minimum of two years of Grievance and Appeals related health insurance experience required. Strong preference for experience in auditing or compliance related role.
Education, Certificates, Licenses: High school diploma or equivalent required. Bachelor’s degree preferred.
Knowledge: Strong computer skills. Excellent verbal and business writing skills. Excellent public relations skills. Good understanding of Medical Terminology required. Requires ability to define and prioritize problems and manage workload without direct supervision.
Competencies:
Adaptability
Building Customer Loyalty
Building Strategic Work Relationships
Building Trust
Continuous Improvement
Contributing to Team Success
Planning and Organizing
Work Standards
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Skills:
Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork
Our Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for customer service.
- We practice open communication at all levels of the company to foster individual, team and company growth.
- We actively participate in efforts to improve our many communities-internally and externally.
- We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
- We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
