Regulatory Consumer Specialist- Claims

Presbyterian Healthcare Services; Albuquerque (NM); Remote; USD 60,000 - 80,000; Full time

Job summary

Join a leading healthcare provider as a Regulatory Consumer Specialist in Albuquerque. You will manage regulatory processes impacting claims, ensuring compliance with Medicare and Medicaid standards while working collaboratively with various teams. This role offers an ideal environment for proactive problem-solvers passionate about improving healthcare processes.

Benefits

Medical, wellness program, vision, and dental coverage

Paid time off

Retirement benefits

Employee Wellness rewards program

Qualifications

• Two or more years of experience in Medicaid, Medicare, or Medicare Advantage claims processing preferred.
• Able to work under limited supervision and self-manage work time.
• Strong understanding of regulatory standards and claims payment guidelines.

Responsibilities

• Acts as the initial contact interface with supervisors regarding regulatory and compliance issues.
• Identifies and resolves regulatory issues, ensuring process changes as needed.
• Participates in developing and monitoring corrective action plans.

Skills

Communication skills

Negotiation skills

PC skills (Word, Excel, Power Point, Visio)

Education

High school diploma or G.E.D. equivalent

Bachelor's degree in related field (preferred)

Job description

Overview

Now hiring a Regulatory Consumer Specialist- Claims

This position is responsible for the overall management of regulatory processes that impact the claims department, with heavy emphasis on the Medicare Advantage and Medicaid lines of business. Responsible for working with department leadership to implement regulatory and plan design processes to meet CMS compliance and member expectations. Under limited supervision, serves as a subject matter expert and replies to requests from external and internal customers. Facilitates resolution of issues or process improvements by using multi-functional teams. Acts as a resource to claims staff to provide guidance for training of policies, procedures and processes, program operations and regulatory changes and requirements

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

• Full Time - Exempt: Yes
• Job is based at Rev Hugh Cooper Admin Center
• Remote work from home: this job is intended to be conducting in the state of New Mexico.
• Work hours: Weekday Schedule Monday-Friday
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.
• Remote: Open to remote applicants in the United States, except for the following states: Wyoming, North Dakota, Ohio, California, New York, Iowa, and Illinois

Ideal Candidate: Two or more years experience in Medicaid, Original Medicare or Medicare Advantage claims processing, preferred.

Qualifications

• High school education or G.E.D. equivalent required. Bachelors degree in related field preferred. Four years experience in healthcare required. Two or more years experience in Medicaid, Original Medicare or Medicare Advantage claims processing, preferred. Able to work under limited supervision, self-manage work time, projects, multi task and resolve complex issues with minimal assistance. Ability to support the decisions of PHP Medicare Advantage, Medicaid and Commercial Compliance Officers and Executive Management. Strong communication and negotiation skills written and verbal. Strong PC skills Word, Excel, Power Point, Visio. Hands on experience with computer systems administration and operations, structure and contract arrangements. Experience with and/or knowledge of contractual or regulatory standards, including audit and claims payment guidelines
• Education:Essential:High School Diploma or GED

Responsibilities

• Acts as the initial contact and interface with Commercial, Medicaid and Medicare Advantage Supervisors/Manager regarding regulatory and compliance issues or concerns. Able to communicate with all levels of management
• Actively seeks to identify and resolve regulatory issues and ensure process changes for HSD guidance memorandums, CMS/DOI Regulations. Brings issues to a higher level when appropriate with complete documentation, research and suggested resolutions. Communicates recommended resolution time frames/corrective action plan (CAP) to Claims Director/Manager
• Participates on cross-functional task forces with representatives from the Health Plan and Claims to address complex issues and tasks to be resolved
• Participates in developing and monitoring corrective action plans with specific tasks and due dates for completion as required by DOI and CMS
• Development and presentation of training programs to the Claims employees. Develops agenda and training materials for the Claims Team meetings related to regulatory or contractual information
• Coordinates the collection of, performance indicators and regulatory reports on a monthly basis. Distributes performance indicators to the Claims/MA leadership team and facilitates discussion regarding actions to take as a result of trends in performance indicators

Benefits

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian? As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Maximum Offer for this position is up to

USD $32.17/Hr.

Compensation Disclaimer

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.