Claims Regulatory Oversight Specialist

Accomplishes business objectives by implementing, identifying and solving customer information and processing problems specific to required communications and reporting of Medicare Advantage and State Medicaid plans in the Claims Department. Maintains continuous oversight of written communications and regulatory reporting for the Medicare Advantage and State Medicaid plans.

Essential Functions & Responsibilities

  • Coordinates the implementation and ongoing upkeep of required communications under Medicare and State Medicaid programs as a result of delegated claims processing.
  • Acts as the primary liaison between the Medicare and Medicaid Health plan and the internal departments of Claims, Compliance and IT in the successful implementation and ongoing upkeep of required communications.
  • Creates a detailed database for purposes of tracking the implementation and upkeep of all required health plan letters.
  • Routinely audits the outcome of health plan letters produced to ensure the templates and distribution of the health plan requirements are being strictly adhered to.
  • Obtains the required sign off and approvals prior to health plan letters and reporting being placed into production.
  • Routinely outreaches to the Medicare Advantage and State Medicaid health plans to inquire on letters implemented to assess if any updates have occurred.
  • Documents the result of all audits and communications related to a health plan letters in the database.
  • Maintains quality service by establishing and enforcing organization standards.
  • Creates a detailed database for purposes of tracking the implementation and upkeep of all required health plan reports.
  • Coordinates the annual implementation of CMS reporting requirements with each contracted Medicare Advantage health plan to ensure Part C and ODAG requirements specific to each health plan are documented, approved and implemented in accordance to health plan interpretation.
  • Coordinates the implementation of any state required Medicaid reporting with each contracted Medicaid health plan so that the plan reporting specifications are adhered to.
  • Validates the results of reporting upon completion to ensure health plan specifications are adhered to.
  • Works directly and in conjunction with IT designee on the successful outcome of regulatory reports and letters as a result of Claims Adjudication.
  • Participates in Health Plan delegation audits with respect to letters and regulatory reporting.
  • Coordinates the activities of any sub delegates of the claims department to ensure they are in compliance with respect to communications and reporting.
  • Documents the activities of the subdelegated in the database.
  • Assists in the upkeep of claims policies on SharePoint to ensure regulatory guidelines are maintained.
  • Complies with all Company HIPAA policies and procedures
  • Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
  • Ability to come to work and work the regular schedule and shift for the position.
  • Compliance with all personnel policies and procedures.
  • Perform additional duties and related essential duties as assigned.

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Required Education and Experience

  • Minimum of 3 years experience in a Compliance related position with emphasis in Medical Claims regulatory communications and reporting requirements under Medicare and State Medicaid plans.
  • Prior Medicare Managed Care claims processing experience related to delegation oversight and auditing.
  • High school diploma or equivalent

Certificates, Licenses, Registrations

N/A

Supervisory Responsibilities

N/A

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