Regulatory Specialist Job at Healthfirst

Job Description

The Regulatory Specialist is responsible for promoting compliance with regulatory requirements with Healthfirst's Utilization Management, Care Management, Appeals and Grievance, or Pharmacy departments and/or delegated vendors. Compliance is promoted ensuring regulatory updates are evaluated, implemented and by performing monitoring to evaluate compliance with regulatory requirements required by, Centers for Medicare and Medicaid Services (CMS) and State Department of Health (DOH) regulations, and business requirements.

Job Responsibility

Promotes compliance with regulatory requirements
Meets with the Regulatory department to organize pre-survey deliverables and conduct reviews of materials
Interacts with and represents the business unit
Responds to auditor requests and audits outcome results
Identifies organizational risks and helps implement process improvements
Manages, coordinates, and participates in the implementation of contract changes for all lines of business pertaining to Utilization Management/Care Management/Appeals & Grievances departments
Ensures that all process and contract changes are reflected in departmental policies and procedures
Reviews Healthfirst policies, procedures, and correspondence to ensure compliance with CMS and DOH regulations
Monitors all Utilization Management/Care Management/Appeals & Grievances corrective action plans (CAPs) through completion
Reviews timeliness of all Utilization Management/Care Management/Appeals & Grievances monitoring reports to assess for compliance with regulatory time frames and develops CAPs if non-compliance is observed
Assists in accreditation submissions, regulatory surveys, and internal audits
Additional duties as assigned
Monitor incoming regulations including those received from Centers for Medicare and Medicaid Services (CMS), State Department of Health (DOH), PBM and internal channels
Share regulatory guidance with Pharmacy department and provide support to ensure regulation and impact are understood
Act as a liaison between Pharmacy Department and Regulatory Affairs/Legal when guidance on interpretation is required
Provide support to Pharmacy Department related to regulatory implementation efforts including: Tracking deliverables to target
Coordinating meeting and collecting deliverables from business units
Capturing action steps
Communicating to leadership
Perform monitoring of timeliness of decision-making and notification compliance standards to ensure adherence with CMS and DOH regulations
Perform monitoring of written notifications for coverage determinations and appeals to ensure compliance with CMS and DOH regulations
Perform monitoring of Medicare Part D grievances to ensure appropriate classification, thorough investigation and response provided to all grievances raised
Performing monitoring of coverage for drugs that may not be covered under Medicare Part D to ensure compliance with CMS requirements
Monitor PBM to ensure timely sharing of complaints and grievances received for non-Medicare lines of business
Maintain dashboard to track monitoring results including areas of non-compliance and process improvements for discussion with PBM and Pharmacy leadership
Identify process gaps or process improvements and collaborate with Pharmacy department and other business units to implement process enhancements
Assist with creating corrective action plans
Attend Regulatory, Pharmacy and departmental meetings, as deemed appropriate

Requirements

High School Diploma or GED
High school diploma or equivalent with at least four (4) years of health care experience
Strong knowledge of CMS and/or New York State DOH regulations
Compliance experience within a managed care environment
Working knowledge of project management
Intermediate MS Word, Excel, PowerPoint, Adobe Acrobat and corporate email systems
Ability to build and maintain positive relationships with cross-functional teams and interact with all levels of management
Time management, critical/creative thinking, project management, communication, and problem-solving skills

Nice to have

Bachelor's degree from an accredited institution
Previous relevant compliance experience
Proficiency with Microsoft systems like Outlook, Excel, and Word
Bachelor's degree preferred in related field
Relevant previous work experience and knowledge of Department of Health (DOH) and Local Department of Social Services and Center for Medicare & Medicaid Services (CMS) regulations pertaining to managed care

What we offer

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions

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Regulatory Specialist

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