Medicaid Compliance Specialist - MetroPlusHealth

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Regulatory Compliance Specialist reports to the Director of Regulatory Compliance.  The Specialist will support the oversight and management of Medicaid regulatory compliance activities, including monitoring of all related regulatory guidance for compliance work plan activities, supporting the organization with corrective actions and regulatory disclosures, contributing to the annual Compliance risk analysis and Work Plan.  Ensuring the Medicaid Compliance plan and related Compliance training are accurate and updated. 

• Contribute to the annual risk assessment and work plan, ensuring the gathering and provision of Medicaid regulatory compliance related information. 
• Supports the regular development and review of Regulatory Compliance policies and procedures for the general operation of the Plan’s compliance program and its’ related activities for Medicare and MAP lines of business.
• Conducts auditing and monitoring activities for Medicaid as outlined in Compliance Work Plan
• Contributes quality and timely data for the materials prepared for both the Internal Compliance Committee Meetings and Audit and Compliance Subcommittee of the Board of Directors. 
• Synthesizes regulatory guidance into Compliance activities and tracking related due dates and providing support to business areas completing deliverables. 
• Upon identification of non-compliance, provide support to business areas in conducting a root cause analysis and corrective actions, including guidance on methodology, identification of relevant regulatory requirements and any regulatory compliance context, and Compliance review.  Plays a critical role in driving the progress for corrective actions throughout the organization.
• Coordinates the support for business areas in creating and updating monitoring metrics to assess continued compliance with regulatory requirements
• Ensures proper investigation of all Medicaid regulatory compliance related issues.
• Other duties as assigned or requested

• A Bachelor’s degree preferred
• CHC, CCEP preferred
• At least 3 years of Managed Care experience

Professional Competencies

• Experience with managed care, Medicare and federal and/or state regulations, quality improvement and compliance oversight
• High-level of skill in leading interdepartmental and cross-functional strategy development; experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met. Simultaneously manage multiple projects
• Excellent oral, written, and presentation skills, as well as conceptual and analytic skills are necessary in order to review and articulate corporate objectives and Federal regulations across all relevant audiences
• The utmost integrity in the discreet and confidential handling of confidential materials is necessary

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