Regulatory Compliance & Member Relations Specialist

Jefferson Health; Jefferson Center (PA); Vor Ort; USD 75.000 - 120.000; Vollzeit

Benefits dieser Stelle

Medical and prescription coverage

Tuition assistance

Dental and vision insurance

Zusammenfassung

Jefferson Health is seeking a compliant and detail-oriented professional to oversee operational compliance for Member Relations. You will monitor CMS, DHS and NCQA guidance across Medicaid and Medicare programs, coordinate with internal teams and vendors, and support audits and training.

You will work closely with management to implement policies, track performance, and ensure timely responses to inquiries. A Bachelor’s degree and 2 years of Medicare/Medicaid experience are required.

Qualifikationen

• Bachelor’s Degree or equivalent work experience.
• 2 years of Medicare and Medicaid operational experience.
• Excellent written and verbal communication skills.
• Ability to manage multiple tasks and adhere to deadlines.
• Proficiency in Departmental Information Systems including DPW, Member Health Information System and Pharmacy Systems.
• Must maintain open communication with government entities and Jefferson management.
• Bilingual is preferred.

Aufgaben

• Serve as a point of contact for CMS, DHS, and OOC communications with internal departments and vendors.
• Review CMS, DHS, OOC and NCQA guidance and its application to Member Relations.
• Develop related processes and policies.
• Monitor and document operational compliance components.
• Communicate with management to ensure regulatory requirements are met.
• Represent Jefferson Health Plans at meetings/workgroups as required.
• Educate staff on compliance updates applicable to day-to-day operations.
• Assist with data collection and organization for audits.
• Maintain records showing timely completion of internal requests.
• Disseminate CMS, DHS, OOC and NCQA guidance to staff and vendors.
• Report trends and issues impacting the department.
• Participate in staff meetings and help create operating procedures.
• Identify training gaps and provide recommendations.
• Monitor call listening for compliance and act as liaison.
• Coordinate cross-functional initiatives and vendor oversight meetings.
• Support mock audits and QA on calls and quality results.
• Monitor call center performance and improvement activities.

Kenntnisse

Excellent written & verbal comms

Multitasking

Independent work

DPW system proficiency

Member Health information system

Pharmacy systems proficiency

Bilingual (preferred)

Update management cadence

Ausbildung

Bachelor’s Degree or equivalent work experience

Tools

DPW

Member Health Information System

Pharmacy Systems

Jobbeschreibung

Jefferson Health is seeking a compliant and detail-oriented professional to oversee operational compliance for Member Relations. You will monitor CMS, DHS and NCQA guidance across Medicaid and Medicare programs, coordinate with internal teams and vendors, and support audits and training.

You will work closely with management to implement policies, track performance, and ensure timely responses to inquiries. A Bachelor’s degree and 2 years of Medicare/Medicaid experience are required.