Medicare Regulatory 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

Reporting to the Senior Manager of Medicare Regulatory Compliance, the Medicare Regulatory Compliance Specialist will support the oversight and management of the Medicare Compliance Program. The Specialist will support Medicare regulatory implementations and the correction and remediation of compliance issues. The Medicare Regulatory Compliance Specialist will assist in driving overall compliance with Medicare requirements.

• Provide implementation oversight by ensuring regulatory requirements have been effectively implemented by the internal and external business areas, including but not limited to:
  • Synthesize regulatory guidance into Compliance activities.
  • Track related due dates, updates and maintains Compliance Department trackers.
  • Escalate items at risk for noncompliance.
  • Ensure business area has implemented regulatory requirements by collecting documentation that demonstrate that the process, operations, trainings, policies, job aides have been updated, as applicable for a compliant close out.
• Conduct compliance reviews of operational policies and procedures to ensure adherence to regulatory and contractual obligations.
• Ensure proper investigation of all Medicare regulatory compliance related issues.
• Supports Compliance leadership in:
  • External audits or regulatory requests as needed.
  • Assisting in the development of the annual risk assessment and implementation of the annual work plan ensuring the gathering and provision of Medicare regulatory compliance related information.
  • 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 the Medicare line of business.
  • Implementation of Compliance Work Plan activities.
  • 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. 
• Other duties as requested

• Bachelor’s degree required.
• 4 years of managed care experience required, preferably in regulatory affairs/compliance.
• Experience with implementation of HPMS Memos, CMS Final Rules and Medicare Managed Manuals.
• Experience with operational implementation of Part C & D requirements and understanding operational workflows and processes.
• Experience in driving corrective action plans (CAPs) and compliance issue resolutions.
• CHC, CCEP Preferred

Professional Competencies

• Strong knowledge and experience with managed care, Medicare regulations/requirements, operational process improvement and compliance oversight.
• Ability to work independently and effectively.
• 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 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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