Member Relations Compliance Rep - JHP

jeffersonhealth; Philadelphia (Philadelphia County); On-site; USD 70,000 - 90,000; Full time

Job summary

Health Partners Plans, Inc. in Philadelphia, PA seeks a Compliance Analyst to monitor operational compliance across Medicaid, Medicare, CHIP PPO, and ACA programs. The role covers CMS, DHS, and NCQA guidance, audit support, and coordination with internal teams and vendors.

The candidate will develop processes, oversee data collection for audits, and educate staff on updates. Strong communication and ability to work independently are essential.

Qualifications

• Bachelor's Degree or equivalent work experience.
• 2 years of Medicare and Medicaid operational experience.
• Excellent written and verbal communication skills.
• Ability to work independently and meet deadlines.
• Proficiency with CMS, DHS, OOC guidance and NCQA standards.

Responsibilities

• Serve as a point of contact for CMS, DHS, and OOC communications.
• Review CMS, DHS, OOC and NCQA guidance and apply to Member Relations.
• Develop related processes and policies.
• Monitor and document operational compliance components.
• Communicate with internal management to ensure regulatory compliance.
• Assist with data collection for audits and maintain records.

Skills

Regulatory compliance

CMS/DHS guidance

Auditing experience

Communication skills

Independent worker

Education

Bachelor's Degree or equivalent

Tools

DPW

Member Health Information System

Pharmacy Systems

Job description

Number of Positions In Requisition

1

Job Details

This position reports to the Manager, Member Relations. Responsibilities include but are not limited to the monitoring of operational compliance requirements. This role requires mastering and demonstrating skills and concepts within all lines of business supported by Member Relations (currently Medicaid, Medicare, CHIP PPO, ACA) in reference to enrollment, appeals and grievances, Complaint Tracking Module, claims, billing, marketing, etc. The specific goal of this position is to effectively monitor and oversee operational measures for both internal member relations teams and affiliated vendors. This position also includes the management of CMS, DHS and OOC communication and assisting with audit objectives. Individual must be able to operate independently.

Hours: Monday thru Friday, 9am -5:30 pm.

Job Description

• Serve as a point of contact for all internal departments and vendor for CMS, DHS, and OOC communications including HPMS issued guidance, and other relevant regulatory and sub-regulatory guidance.
• Review of CMS, DHS, OOC and NCQA guidance and how it applies to Member Relations and related first tier downstream entities.
• Development of related processes and policies.
• Monitoring and documentation of operational compliance components.
• Effectively communicate with various internal management teams to ensure compliance with contractual/regulatory requirements.
• Act as a representative of Jefferson Health Plans at internal and external meetings/workgroups, etc., as required or requested.
• Educate staff on compliance updates and how it applies to day to day operations for areas of responsibility.
• Assist with data collection and organization for Medicare, CHIP, NCQA and Medicaid audits, internal - external.
• Maintain records to demonstrate timely completion of all internal requests.
• Assist management in reviewing, clarifying and disseminating CMS, DHS, OOC and NCQA guidance to appropriate Jefferson Health Plans Member Relations staff and associated vendors.
• Report on trends and issues that impact the Member Relations Department staff.
• Participate in appropriate staff meetings. Responsible for the documentation and creation of operating procedures.
• Identify Training gaps/needs. Provide recommendations and feedback.
• Call listening to monitor for compliance and standard process. Act as an interdepartmental liaison.
• Coordinate cross-functional and interdepartmental initiatives. Facilitate training sessions and vendor oversight meetings.
• Mock audit activity as needed.
• Test calls- including the monitoring/documentation of quality results.
• Monitoring of call center performance. Track performance outcomes and improvement activities.
• May perform other duties as assigned.

Education

• Bachelor's Degree or equivalent work experience.

Experience

• 2 years of Medicare and Medicaid operational experience.

Knowledge, Skills and Abilities - Required

• Excellent written and verbal communication skills.
• Ability to manage multiple tasks and adhere to deadlines.
• Ability to work independent of direct supervision, but also must be able to meet and exceed deadlines for close turnaround timeframes.
• Proficiency in Departmental Information Systems including DPW, Member Health Information System and Pharmacy Systems.
• Must possess ability to provide continual updates to management on all issues, bringing those with potential impact to the attention of management immediately.
• Ability to maintain open, amicable communication with government entities, and Health Partners management, in an effort to ensure development of a "partnership" relationship.

Knowledge, Skills and Abilities - Preferred

• Preferred demonstrated experience across multiple Medicare, Medicaid, OOC and NCQA disciplines i.e. CTM, call center, grievances, and monitoring.
• Bilingual a plus, but not necessary.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs