Medicare Program Analyst

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

The Regulatory Compliance Associate is responsible for the identification and communication of new, revised, and pending federal and state laws, regulations, and standards relevant to a Horizon Lines of Business (LOB). This position administers and coordinates the functions associated with compliance and regulatory guidelines related to each market and will develop and maintain standard operating policies and procedures, compliance reporting and dashboards, and execute the annual Compliance workplan. This position will work with business to ensure compliance with relevant agencies including but not limited to: Centers for Medicare & Medicaid Services (CMS), Division of Medical Assistance and Health Services (DMAHS), Get Covered New Jersey and The New Jersey Department of Banking and Insurance (DOBI). Regulatory Compliance Associates collaborate with internal divisions to foster a compliant culture and ensure regulatory compliant materials and activities.

Responsibilities:

• Maintain knowledge of all relevant legislative and regulatory health plan requirements and monitor information sources for changes in regulatory compliance program requirements for Horizon’s LOBs.

• Analyze information and determine what is informational versus change affecting organizational processes.

• Review, interpret, summarize and communicate new and revised requirements to the business unit personnel using multiple distribution methods.

• Provide plain language compliance guidance and direction to operationalize regulatory compliance requirements and support implementation of changes stemming from new or revised State and Federal requirements.

• Oversee compliance with new, revised, and pending regulatory requirements through the Requirements Database, and collect and evaluate evidence of compliance submissions from business unit personnel.

• Support and actively participate in annual team functions including monitoring, ongoing risk assessment, audit readiness activities, external audit coordination, executing the compliance workplan, and other divisional priorities related to risk mitigation.

• Gather relevant data and Key Performance Indicators for compliance reports and dashboards, and prepare reports based on established reporting metrics for the group.

• Independently investigate areas of non-compliance, and act on matters by designing and coordinating internal investigations and resulting corrective action plans with all departments.

• Identify potential non-compliance vulnerabilities and make practical business recommendations to correct non-compliance or improve insufficient processes.

• Monitor business units’ self-monitoring results to ensure that current procedures satisfy regulatory requirements and are sufficient to detect future instances of non-compliance. Assist with the development of compliance policies, control processes, self-monitoring, and self-auditing tools that promote maintaining compliant business processes.

• Develop and update Standard Operating Policies and Procedures (SOP) for review processes and compliance.  Educate stakeholders on these SOPs.

• Develop collaborative relationships with regulators. Monitor compliance related commitments made to regulatory agencies governing Horizon’s LOBs, and review and maintain submissions, reports, and filings to regulators.

Addendum (Medicare):

• Actively participates in the annual product implementation, including providing guidance on and facilitating review and approval of all materials related to product implementation (i.e. annual notices of change, evidence of coverage documents, formulary and provider related material and model operational letters).

• Serve as a subject matter expert on the CMS (Center for Medicare & Medicaid Services) Medicare Marketing Guidelines (MMG) for Horizon's Medicare products. Establish and maintain a comprehensive understanding of all CMS and State requirements related to Medicare Advantage, Medicare Part D and Medicaid requirements, for the special needs plan, with respect to marketing and related materials.

• Develop and maintain tools to facilitate and report on the internal review of materials (e.g. internal CMS Submission Database; SharePoint site functionality) consistent with evolving CMS and DMAHS marketing guidelines.

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to