Commercial Regulatory Guidance Specialist

MetroPlus; New York (NY); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Commercial Compliance Specialist to ensure adherence to healthcare regulations and policies. This role involves collaborating with various teams to implement compliance measures, conduct audits, and provide guidance on regulatory matters. The ideal candidate will have a strong background in managed care, excellent communication skills, and the ability to navigate complex regulatory environments. Join a mission-driven organization dedicated to empowering communities through care and make a meaningful impact in the healthcare sector. If you are passionate about compliance and want to contribute to a vital mission, this opportunity is perfect for you.

Qualifications

• Bachelor's degree and 3+ years of managed care experience required.
• Knowledge of ACA and CMS guidelines essential.

Responsibilities

• Ensure compliance with ACA, CMS, and state regulations for products.
• Conduct compliance reviews and audits to identify issues.
• Provide guidance on compliance matters to internal stakeholders.

Skills

Healthcare regulations knowledge

Compliance auditing

Interdepartmental collaboration

Analytical skills

Oral and written communication

Education

Bachelor's degree

Tools

Compliance management systems

Job description

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

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, and Essential Plan. 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 Commercial Compliance Specialist reports to the Director of Regulatory Compliance. The position will support the oversight and management of QHP, EP, CHP, and large group products. This position requires knowledge of healthcare regulations and policies, and the ability to interpret and apply them in a complex and dynamic environment. The Commercial Compliance Specialist will collaborate closely with internal stakeholders to implement policies and procedures, conduct compliance reviews, and provide guidance on compliance matters.

Job Description

• Ensure compliance with Affordable Care Act, CMS guidelines, and state-specific regulations for marketplace and large group products.
• Provide guidance on compliance matters to internal stakeholders, including senior management, sales and marketing, and product development teams.
• Conduct compliance reviews and audits to identify and address compliance issues.
• Identify compliance risks and contribute to the development of the annual compliance risk assessment and work plan.
• Conduct auditing and monitoring activities as outlined in the compliance work plan.
• Stay up to date on changes in regulations and policies affecting marketplace and commercial products.
• Communicate compliance issues and developments to internal stakeholders.
• Upon identification of non-compliance, provide support to business areas in conducting a root cause analysis and corrective actions.
• Play a critical role in driving the progress for corrective actions throughout the organization.
• Ensure implementation of new policy guidance and regulatory provisions.
• Review supporting implementations, demonstrating compliance with new regulatory provisions.
• Review operational policies and procedures to ensure adherence to regulatory requirements.
• Provide support for full operational external regulatory audits.
• Ensure timely implementation of corrective actions from state regulatory audits.
• Provide updates and data for materials prepared for Internal Compliance Committee Meetings and Audit and Compliance Subcommittee of the Board of Directors.
• Coordinate support for business areas in creating, updating, and monitoring metrics to assess continued compliance with regulatory requirements.
• Other duties as assigned or requested.

Minimum Qualifications

• Bachelor’s degree; and
• At least 3 years of managed care experience; or
• A satisfactory combination of education, experience, and training.
• CHC, CCEP preferred.
• Knowledge of healthcare regulations and policies, including Affordable Care Act, CMS guidelines, and state-specific regulations for government, individual, and group insurance policies.
• High-level skill in leading interdepartmental and cross-functional workgroups; and managing multiple projects to ensure corporate deadlines and objectives are met.
• Ability to operationalize complex regulatory provisions, laws, and statutes.
• 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.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

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