Regulatory Operations Manager

phsorg; United States; On-site; USD 76,000 - 129,000; Full time

Benefits offered by this job

Medical, dental, vision

Short-term & long-term disability

Life insurance

Employee Wellness program

Job summary

Presbyterian Health Plan (PHP) is seeking a Regulatory Operations Manager to lead regulatory activities for commercial, Medicaid and Medicare Advantage lines. You will identify and implement regulatory changes, coordinate agency inquiries, and perform complex analyses to help business owners meet state and federal requirements.

Interaction with PHP staff and regulators is essential. The role requires a Bachelor's degree and 3–5 years in health plan management/regulatory/compliance, with strong

Qualifications

• Bachelor's degree required.
• 3–5 years experience in health plan management and regulatory/compliance.
• Experience with health insurance regulation preferred.
• Ability to influence others and manage multiple activities simultaneously.

Responsibilities

• Lead regulatory operations in alignment with PHP leadership and Legal Counsel.
• Respond to regulatory inquiries, audits, and reporting requirements for insurance products.
• Track and interpret federal/state laws and regulatory changes impacting PHP products.
• Translate laws into practical policies and guidelines for business areas.
• Support CAP elements and compliance monitoring activities across departments.
• Participate in regulatory liaison activities with various stakeholders.

Skills

Regulatory compliance

Health plan management

Regulatory/legal experience

Ability to manage multiple activities

Education

Bachelor's Degree

Job description

Now Hiring: Regulatory Operations Manager

Location Address:
9521 San Mateo NE
Albuquerque, NM 87113-2237

Compensation Pay Range:
Minimum Offer $75,732.80
Maximum Offer $128,960.00

Type of Opportunity: Full time

Job Exempt: Yes

Job is based: Reverend Hugh Cooper Administrative Center

Work Shift: Days (United States of America)

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.

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.

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.
• 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 co