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Location

Owings Mills, MD | United States

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Job description

Resp & Qualifications

PURPOSE:

The Senior Regulatory Compliance Analyst (Medicaid) will conduct independent analysis for complicated, high level regulatory inquiries and provide interpretation of regulatory rules and guidelines to demonstrate compliance with state and federal requirements. The incumbent will audit internal controls to identify high risk exposure, will provide recommendations to business areas and will track implementation of remedial solutions.

ESSENTIAL FUNCTIONS:

Relationship Management: (Internal/External)

Liaison with Regulatory Agency Investigators (Maryland Insurance Administration {MIA}, Virginia Bureau of Insurance {VBOI} and the District Insurance, Security and Banking {DISB}, organization as well as state and federal level bureaucrats. Frequent interaction with all internal areas especially all Business Units, Legal, Compliance and Legislative Departments. Provide interpretation of regulations and regulatory rules/guidelines to demonstrate CareFirst BCBS and its subsidiaries' compliance with state and federal standards. Review and analyze all data received in order to generate detailed responses to the originating party. Strategizes with Legal and Compliance as needed to identify the best response to the complaint. Consistently maintains highly professional written and verbal interaction with all levels of staff within the company and with all members within regulatory departments. Maintain positive, responsive, respectful relationships with all regulators. Serves as the subject matter expert for business processes and related systems as the representative of the company. Provide education regarding systems and process to regulators as needed and requested.

Business Support

Research, resolve and respond to written inquiries forwarded from Congressional, Attorney General and State officials, members, providers, groups and brokers. Coordinate with internal and external parties to ensure accurate information is obtained. Review and analyze provided data and information. Provide detailed professionally written responses to originating party, ensuring all questions are answered and customer needs are effectively served within designated timeframes while ensuring privacy needs of members are respected. Review, analyze, prepare detailed documentation for support of legal action pertaining to CareFirst indemnity business, ensuring that all appropriate materials, related claims, contracts, payment vouchers are included. Develop a summary/assessment of included documentation for legal staff. Meet, discuss, and strategize with legal staff to prepare for depositions, court cases or administrative hearings. Appear as required to testify on behalf of CareFirst.

System Compliance Analysis

Review moderately complex business processes and systems to identify, document, elevate the presence of risks and trends within systems and processes that may be non-compliant with contracts and or statutory requirements especially in the claims processing, enrollment and service arenas all jurisdictions, all products, all processing platforms to include our subsidiaries. Actively participate in implementation/corrective workgroups to ensure compliance perspective and concerns are addressed through the process.

Litigation and Legal Support

Review, analyze, prepare detailed documentation for support of legal action pertaining to CareFirst indemnity business, ensuring that all appropriate materials, related claims, contracts, payment vouchers are included. Develop a summary/assessment of included documentation for legal staff. Meet, discuss, and strategize with legal staff to prepare for depositions, court cases or administrative hearings. Appear as required to testify on behalf of CareFirst

Special Projects

Provide research, investigative and analytic support on special projects ensuring that all CareFirst policies and contractual guidelines are clearly identified. Provide support to supervisors and other internal associates with written responses to inquiries.

QUALIFICATIONS:

Education Level: Bachelor's Degree OR In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience: 5 years experience in a compliance or senior level customer service role. Medicaid Managed Care or PBM compliance experience is preferred.

Knowledge, Skills and Abilities (KSAs)

• Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
• Ability to convey information in a clear, concise, and logical manner.
• Ability to effectively convey information to others.
• Excellent critical thinking and communication skills both written and verbal.
• Consistently maintains highly professional written and verbal interaction with all levels of staff within the company and with members of regulatory agencies.
• Must be able to interpret insurance law and regulations.
• The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
  Salary Range: $64,800 - $128,700

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

#LI-LJ1

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Job tags

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