Manages interactions with state regulators/business partners, establishing policies and procedures to ensure the organization's full compliance with all applicable state, federal, and local government rules and regulatory requirements, contractual requirements, and licensing of business operations. Maintain corporate and regulatory compliance as an essential part of our business strategy to operate as effectively as possible.
Primarily responsible for contracting for services delivered at Nicklaus Children's Health System and Pediatric Specialists of America in collaboration with the Director of Managed Care and Payer Strategy. Assists in the negotiation, analysis, and implementation of moderate to complex health plan agreements and employed physician contracts with payers, LOAs, and other managed care arrangements to meet NCHS' financial objectives. Maintains excellent working relationships with managed care partners and third party payors, manages and resolves issues that affect contract performance, and manages issues escalated by internal customers.
Knowledge, Skills, and Abilities
Master's degree preferred.
Proficiency in Microsoft Excel, Word, Access, and PowerPoint.
3-5 years of experience in dealing with contract management and State Health Insurance preferred.
Experience in fraud, waste, and abuse detection preferred.
Ability to plan time effectively, balance multiple tasks, work within stringent time frames, and execute projects to completion.
Ability to research legal, regulatory, and contractual documents for interpretive purposes.
Conflict resolution and problem-solving skills.
Good written and oral communication skills.
Skilled in financial analysis and management and strong analytical ability.
Understanding of state and federal regulatory guidelines relevant to the applicable service area.
Ability to travel.
Job Specific Duties
Maintains excellent working relationships with state agency and business partner for the health plan. Manages and resolves issues that affect contract obligations, performance, and manages issues that are escalated by the agency.
Leads process for interactions (question and answer, follow-up requests, etc.) between state regulatory agency to client health plans and facilitates resolution of those requests with business partner.
Provides compliance and the health plan leadership team with the development, implementation, and revision of all Health System policies, procedures, documents, and forms related to the general operation of the organization, as well as the health plan compliance program.
Coordinates with internal team members to ensure state contractual terms are being met.
Researches emerging, new, and existing regulations; industry standards; and regulatory movements that impact the Health System's ability to operate or pose risk of non-compliance.
Assists the CCO to establishes compliance operational strategies, establish critical measurements, resolve problems, and recommend and implement change to ensure compliance with internal and external requirements.
Tracks and monitors the completion of all required reports, forms, and filings to ensure accurate and timely submission to the appropriate regulatory authority.
Provides insight, demonstrates trends, and provides analysis of provider compliance.
Assists the CCO to develop and implement compliance and related training programs to ensure all employees, vendors, and business associates receive and appropriately acknowledge all mandatory training.
Ensures compliance with contractual requirements, internal policies and procedures, and federal, state, and local government rules and regulations.
Develops and implements an audit plan to ensure adequate management and control processes to maintain accuracy and quality of all insurance functions.
Reviews and provides input on all form filings and community outreach materials prior to submission to the applicable regulatory agency.
Conducts or directs the internal investigation of compliance issues and maintains records of compliance activities, including complaints or investigations.
Manages all compliance-related communication within the health plan and business partner in an efficient and timely manner to enhance the understanding of compliance throughout the organization while promoting a culture of compliance at all levels within the organization.
Minimum Job Requirements
Bachelor's Degree Healthcare Administration, Health Law, or related field
4-7 years Managed care, health law, project management, or similar experience in healthcare or insurance