Regulatory Consumer Specialist- Claims
US-NM-Albuquerque
Careers (External)
Req #: 47884
Type: Full Time
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Overview: Now hiring a Regulatory Consumer Specialist- Claims This position is responsible for the overall management of regulatory processes that impact the claims department, with heavy emphasis on the Medicare Advantage and Medicaid lines of business. Responsible for working with department leadership to implement regulatory and plan design processes to meet CMS compliance and member expectations. Under limited supervision, serves as a subject matter expert and replies to requests from external and internal customers. Facilitates resolution of issues or process improvements by using multi-functional teams. Acts as a resource to claims staff to provide guidance for training of policies, procedures and processes, program operations and regulatory changes and requirements How you belong matters here. We value our employees' differences and find strength in the diversity of our team and community. At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members. Why Join Us * Full Time - Exempt: Yes * Job is based at Rev Hugh Cooper Admin Center * Work hours: Weekday Schedule Monday-Friday * Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees. Ideal Candidate: Two or more years experience in Medicaid, Original Medicare or Medicare Advantage claims processing, preferred. Responsibilities: * Acts as the initial contact and interface with Commercial, Medicaid and Medicare Advantage Supervisors/Manager regarding regulatory and compliance issues or concerns. Able to communicate with all levels of management * Actively seeks to identify and resolve regulatory issues and ensure process changes for HSD guidance memorandums, CMS/DOI Regulations. Brings issues to a higher level when appropriate with complete documentation, research and suggested resolutions. Communicates recommended resolution time frames/corrective action plan (CAP) to Claims Director/Manager * Participates on cross-functional task forces with representatives from the Health Plan and Claims to address complex issues and tasks to be resolved * Participates in developing and monitoring corrective action plans with specific tasks and due dates for completion as required by DOI and CMS * Development and presentation of training programs to the Claims employees. Develops agenda and training materials for the Claims Team meetings related to regulatory or contractual information * Coordinates the collection of, performance indicators and regulatory reports on a monthly basis. Distributes performance indicators to the Claims/MA leadership team and facilitates discussion regarding actions to take as a result of trends in performance indicators Qualifications: * High school education or G.E.D. equivalent required. Bachelors degree in related field preferred. Four years experience in healthcare required. Two or more years experience in Medicaid, Original Medicare or Medicare Advantage claims processing, preferred. Able to work under limited supervision, self-manage work time, projects, multi task and resolve complex issues with minimal assistance. Ability to support the decisions of PHP Medicare Advantage, Medicaid and Commercial Compliance Officers and Executive Management. Strong communication and negotiation skills written and verbal. Strong PC skills Word, Excel, Power Point, Visio. Hands on experience with computer systems administration and operations, structure and contract arrangements. Experience with and/or knowledge of contractual or regulatory standards, including audit and claims payment guidelines * Education: Essential: High School Diploma or GED
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