Medicaid Regulatory Compliance Specialist

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview 

The Medicaid Regulatory Compliance Specialist reports to the Manager of Medicaid Regulatory Compliance. The position will support the oversight and management of Medicaid, HIV SNP, HARP, EP, and CHP product compliance activities, including ensuring the implementation of regulatory requirements and the correction of issues of noncompliance. The position will also provide support for the development and implementation of the annual risk assessment and work plan and the department’s management of external regulatory audits.

• Provides implementation and oversight by ensuring state policy changes and updates have been effectively implemented. This includes (but is not limited to):
  • Synthesizing regulatory guidance into Compliance activities;
  • Tracking related due dates and providing support to business areas completing deliverables;
  • Manage entry of regulatory changes in a compliance database system;
  • Escalating items at risk for noncompliance;
  • Ensure a compliant close out of implementations, including but not limited to documentation review
• Conducts a compliance review of operational policies and procedures for adherence to regulatory and contractual obligations.
• Ensures proper investigation of all Medicaid regulatory compliance related issues.
• Supports the Manager of Medicaid Regulatory Compliance in:
  • Assisting in the development of the annual risk assessment and implementation of the annual work plan ensuring the gathering and provision of Medicaid regulatory compliance related information;
  • The regular development and review of 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 including;
  • Implementation of Compliance Work Plan activities;
  • Contributes 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. 
  • Other duties as assigned or requested.

• 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. Support the operational areas in the implementation of such policies, procedures, and other changes as required.
• Experience with managed care, Medicaid and federal regulations, quality improvement and compliance oversight.
• High-level of 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, state 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.

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