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Medicaid Regulatory Compliance Specialist
2 months ago
MetroPlusHealth is dedicated to delivering exceptional healthcare services to the residents of New York City. As a leading provider of Medicaid managed care, we are committed to empowering New Yorkers by uniting communities through care. Our mission is to provide the highest quality healthcare services, ensuring that every individual has access to the care they need to thrive.
About MetroPlusHealthMetroPlusHealth is a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States. With a network of over 27,000 primary care providers, specialists, and participating clinics, we offer a comprehensive range of products, including New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, and Essential Plan. Our team is dedicated to building strong relationships with our members and providers to enable New Yorkers to live their healthiest lives.
Job SummaryThe Medicaid Regulatory Compliance Specialist will play a critical role in supporting the oversight and management of Medicaid, HIV SNP, HARP, EP, and CHP product compliance activities. This position will ensure the implementation of regulatory requirements and the correction of issues of noncompliance. The successful candidate will also provide support for the development and implementation of the annual risk assessment and work plan, as well as the department's management of external regulatory audits.
Key Responsibilities- Provide implementation and oversight by ensuring state policy changes and updates have been effectively implemented.
- Synthesize regulatory guidance into Compliance activities.
- Track related due dates and provide support to business areas completing deliverables.
- Manage entry of regulatory changes in a compliance database system.
- Escalate items at risk for noncompliance.
- Ensure a compliant close out of implementations, including but not limited to documentation review.
- Conduct a compliance review of operational policies and procedures for adherence to regulatory and contractual obligations.
- Ensure proper investigation of all Medicaid regulatory compliance related issues.
- Support the Manager of Medicaid Regulatory Compliance in developing the annual risk assessment and implementation of the annual work plan, ensuring the gathering and provision of Medicaid regulatory compliance related information.
- Regularly develop and review Regulatory Compliance policies and procedures for the general operation of the Plan's compliance program and its related activities for the Medicaid lines of business.
- Contribute quality and timely data for the materials prepared for both the Internal Compliance Committee Meetings and Audit and Compliance Subcommittee of the Board of Directors.
- Bachelor's degree required.
- 4 years of managed care experience required, preferably in regulatory affairs/compliance.
- Knowledge of and experience working with NY Medicaid Managed Care contract, Article 44 & 49 and federal Medicaid regulatory requirements.
- Experience with Article 44 operational and targeted audits.
- Experience in operational implementation of Medicaid contract and regulatory requirements.
- Experience in driving Corrective Action Plans (CAPs) and Process Improvement Plans (PIPs).
Professional Competencies
- Broad-based in-depth knowledge of the managed care industry, including strategic compliance planning, regulatory concerns, compliance requirements, and corporate integrity principles.
- Ability to comprehend and interpret regulatory, legislative, and contractual mandates.
- Provide support, feedback, and direction in the development of policies, procedures, and other operational changes necessary to comply with regulatory, legislative, and contractual mandates.
- Experience with managed care, Medicaid, and federal regulations, quality improvement, and compliance oversight.
- High-level project management skill in leading interdepartmental and cross-functional projects; experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met.
- Excellent oral, written, and presentation skills, as well as conceptual and analytic skills, are necessary to review and articulate corporate objectives and Federal regulations across all relevant audiences.
- The utmost integrity in the discreet and confidential handling of confidential materials is necessary.
