Regulatory Operations Manager

Presbyterian Healthcare Services; Albuquerque (NM); On-site; USD 76,000 - 129,000; Full time

Job summary

Presbyterian Healthcare Services in Albuquerque, NM seeks a Regulatory Operations Manager to lead the regulatory operations team and ensure compliant administration of health plan products including commercial, Medicaid, and Medicare Advantage. Responsibilities cover regulatory research, coordinating agency inquiries, and implementing new regulations across PHP’s insurance products.

The role involves collaborating with legal, compliance, and business units to minimize risk and ensure adherence

Qualifications

• Bachelor's degree required.
• Three to five years experience in health plan management and regulatory/legal or compliance.
• Specific experience with health insurance regulation preferred.
• Demonstrated ability through education and experience to manage compliance with laws and regulations.
• Can orchestrate multiple activities simultaneously to accomplish a goal, and use resources effectively and efficiently.
• Able to influence others without direct reporting relationship.

Responsibilities

• Work with leadership to ensure compliance with contractual and regulatory requirements.
• Support regulatory inquiries, reporting requirements, audits, and site visits.
• Track federal and state laws, regulations, and new legislation; present changes.
• Translate laws and contractual obligations for departmental teams.
• Provide analysis and recommendations on program standards under Legal Counsel guidance.
• Assist with monitoring CAP elements and compliance initiatives.
• Assist with compliance program activities, staff training, and investigations.
• Maintain tools for audit preparedness.
• Participate in legal and compliance team meetings.

Skills

Regulatory compliance

Policy interpretation

Cross-functional collaboration

Regulatory liaison

Education

Bachelor's degree

Job description

Location Address

9521 San Mateo NE Albuquerque, NM 87113-2237

Compensation Pay Range

Minimum Offer $75,732.80 Maximum Offer $128,960.00 Now Hiring: Regulatory Operations Manager

Summary

The Regulatory Operations Manager supports leadership of the Regulatory Operations department with various insurance product regulatory and/or compliance-related activities. Product lines include commercial, Medicaid and Medicare Advantage; managers will have a specific area of focus but will support other product lines as needed. Major duties include, but are not limited to, assisting leadership with identifying and implementing new and revised regulations, coordinating responses to regulatory agency inquiries, and performing regulatory research and analyses to assist business owners with meeting regulatory requirements of the various state and federal regulatory agencies to whom Presbyterian Health Plan (PHP) is accountable. These regulatory agencies include, but are not limited to, CMS, HSD, DOI, OPM (FEHBP) and DOL (ERISA). The Regulatory Manager is required to interact directly with PHP staff, other PHS staff and the staff of various regulatory entities. Performs comprehensive, complex regulatory analyses, including the review, summarization and dissemination of key regulatory updates and changes. Performs highly complex technical and analytical work under minimal supervision in support of the PHP insurance products. Works with business areas, legal and compliance staff to ensure compliant business practices and to minimize PHP risk levels through the development and interpretation of policies, procedures and guidelines. Performs other regulatory functions as assigned. Type of Opportunity: Full time Job Exempt: Yes Job is based: Reverend Hugh Cooper Administrative Center Work Shift: Days (United States of America)

Responsibilities

• Works closely with the leadership, PHP Director of Regulatory Operations and/or Legal Counsel, other health plan leaders; serves as health plan regulatory liaisons to service areas to: (1) ensure compliance with contractual and regulatory requirements; (2) identify compliance issues associated with new regulations/guidance and ensure their incorporation into all appropriate health plan operations.
• Supports regulatory inquiries, reporting requirements, and audits regarding insurance products. This function includes collecting materials, reviewing and quality checking information and materials, and site visit facilitation as part of normal operations and expansion opportunities.
• Tracks federal and state laws, regulations, and new legislation related to the PHP insurance products. Presents key changes and major initiatives at various internal meetings.
• Acts as a resource for departmental regulatory liaisons and other functional area leaders by translating and interpreting laws and regulations and/or contractual obligations, supporting their implementation.
• Under direction of Legal Counsel, provides analysis and recommendations to functional area leaders on program standards.
• As needed, assists compliance with monitoring/auditing of business practices to ensure ongoing compliance and to minimize of PHP insurance product risk levels through collaboration with departmental regulatory liaisons and other functional area leaders in the development and interpretation of policies, procedures and guidelines. Assists the organization with implementing and monitoring CAP elements. Suggests change initiatives to enhance compliance effort.
• As needed, assists with compliance program activities, such as staff training, policy and procedure development, compliance investigations, audits, and communication with functional areas.
• Maintains tools for audit preparedness.
• Participates in PHP legal and compliance team meetings, as well as other functional area team meetings.

Qualifications

• Bachelors Degree required. Also required: three to five years experience in:
• Health plan management and
• Regulatory/legal or compliance
• Specific experience with health insurance regulation preferred
• Demonstrated ability through education and experience to manage compliance with laws and regulations
• Can orchestrate multiple activities simultaneously to accomplish a goal, as well as use resources effectively and efficiently
• Able to influence others without direct reporting relationship

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.

We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services