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Job Summary

The Specialist is responsible for the maintenance, revision, and implementation of Policies and Procedures to ensure compliance with applicable regulatory standards and contractual obligations. They will be responsible to prepare, develop and make recommendations by analyzing reports and operational data to support operational improvements and enforcement of established standards. In this role, the Business Specialist will work collaboratively with overall operations management team to develop operational efficiencies, maintain contractual requirements, and overall compliance of core operations is in conformity with various rules and regulations.

Maintains compliance with all applicable regulatory requirements.
Effectively prioritizes projects to ensure the highest level of customer satisfaction for PSERS Regulatory and Quality Improvement Activities.
Conducts continual research of new and revised accreditation and regulatory standards applicable to CMS in collaboration with external PSERS vendors.
Maintains a database of regulatory requirements applicable to PSERS processes.
Responsible for the ongoing maintenance and revision of PSERS Division and Utilization Management Policy.
Acts as the Department Liaison for maintenance of required Regulatory Filings/Reports and CMS Inquiries.
Collects, analyzes and reports on key metrics inclusive of identifying trends, barriers, conducting root cause analysis when applicable and providing objective recommendations.
Recommends process improvements for every day operating procedures.
Assists with the ongoing analysis of the PSERS Program to identify opportunities for process improvement, reengineers processes to improve efficiencies and to ensure compliance.
Provides expertise in regulatory/accreditation issues/inquiries for all PSERS functional areas.
Maintains a positive and educational approach when interacting with both internal and external customers in explaining the Regulatory Compliance Program wants and needs
Assists with the orientation of personnel and positively contributes to the ongoing networking of expertise with colleagues
Compiles information via data sources and provides back up support for system administration collecting, analyzing, and summarizing information.
Works collaboratively with management team to work on identified trends and issues for short term and long term resolution, leveraging people, process, technology, and team communications/tools are updated.
Coordinates processes to ensure that information systems support departmental business operational needs.
Promptly review Medicare Part A/D changes and determine impact to PSERS operations.  Share the information with operational team and assess impact, implementing changes as needed, to ensure proper tools and educational information is shared with front line team members or impacted individuals.
Review eligibility and customer service audits, as well as Medicare program audits, to assess steps needed to be taken to correct issues, report and respond to CMS.
Serves as the first point of contact for coworkers and departmental liaisons regarding the use of designated systems.
Provides support for the Director of Operations, System Administrator, and Documentation specialist
Other duties as needed/assigned.

Required Job Qualifications:

High School Diploma
Minimum three to five years’ experience with insurance operations, business or technical experience specific to claims, customer service or enrollment
Ability to work in a fast-paced, customer service & production driven environment
Excellent verbal and written communication skills
Ability to work effectively with employees/members, providers, and differing levels of co-workers and all levels of staff
Ability to use common sense understanding to carry out instructions furnished in oral, written or diagram form
Flexible; open to continued process improvement
Self-directed individual who works well with minimal supervision
Good leadership, organizational and interpersonal skills
Ability to give direction and provide feedback
Demonstrated critical thinking skills
Ability to effectively deal with problems in varying situations and reach resolution
Ability to learn new/proprietary systems, to adapt to various system platforms, and to effectively use MS Excel/Word
Previous working knowledge of Medicare and CMS regulations


Preferred Job Qualifications:

Self-Funded or Fully-Funde