Regulatory Compliance Specialist

3 days ago

East Longmeadow, Massachusetts, United States The MH Group LLC Full time
Job Description

The ideal candidate will have experience in the health insurance industry, specifically in interpreting and applying managed care state and federal laws and regulations to daily operations. The candidate should be familiar with PPO network operations and the oversight of policies and procedures. A solid ability to meet deadlines is essential.

Key Responsibilities:

  • Collaborate with the Provider Network Manager and regulatory staff to ensure all provider network adequacy, managed care, and accreditation regulatory filings and reports are complete and submitted by state and federal deadlines.
  • Under the guidance of the Provider Network Manager, oversee the daily work of regulatory and filing analysts and specialists. Manage timesheets and time off requests.
  • Train, coach, and conduct one-on-one meetings with provider network regulatory and filing staff.
  • Oversee and assist with coordinating new and revised regulations affecting provider networks, ensuring alignment with internal carrier and PPO network policies and procedures to meet regulatory requirements.
  • Analyze regulations, understand their impact on current organizational processes or procedures, identify necessary changes, and implement those changes.
  • Maintain a regulatory tracking calendar and state grid to monitor compliance and revisions needed in policies and procedures.
  • Engage in strategic planning to ensure all regulatory tasks are completed promptly.
  • Manage and assist with state accreditation and re-accreditation filings, managed care filings, and state and federal regulatory reports.
  • Coordinate and complete new and revised regulations, tracking them in the RegEd system.
  • Participate in internal regulatory oversight meetings with internal departments and external calls with PPO networks and vendors to ensure regulatory compliance.
  • Monitor and calculate provider team regulatory key performance metrics (KPMs).
  • Assist the Provider Network Manager with ad-hoc projects that support the provider network and benefit the company as a whole.
  • Perform other duties as assigned.

Requirements:

  • Three to five years of experience in the health insurance and regulatory industry.
  • Strong attention to detail and accountability to take ownership of all work, coupled with robust multi-tasking skills.
  • Excellent writing, communication, and interpersonal skills.
  • Ability to work both independently and as part of a team.
  • Highly oriented problem solver with superior time management skills.
  • Proficiency in MS Office products, including Outlook, Excel, and Word.
  • Skills in interpreting and applying state and federal laws and regulations.
  • Familiarity with accreditation filings and NCQA standards is preferred.
  • Experience with the RegEd system is preferred.
  • Comprehensive understanding of health insurance operations (e.g., eligibility, billing, claims, PPO networks).
  • Experience with the SERFF filing system is preferred.
  • Previous experience in paralegal and/or regulatory analysis work is preferred.
  • Associate's degree in Health Administration, Business Administration, Regulatory Science, or an equivalent combination of education and experience in a related field.

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