Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Medicare Regulatory Operations Lead

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Manager & Professional
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EmblemHealth
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Summary:
  • Work closely with assigned business department(s) to ensure full compliance with all relevant CMS rules and regulations.  
  • Provide regulatory and operational subject matter expertise, both clinical and administrative, for interpretation, testing, monitoring and adherence to Medicare requirements, including filling existing knowledge, skill and monitoring gaps in the business operations while increasing oversight and support for critical Product compliance regulatory activities. 
  • Identify, interpret, and communicate new and revised Medicare regulatory requirements; collaborate on implementation of new or revised regulatory changes, monitoring, tracking, and testing implementation of all Product requirements.
  • Implement processes and reports to assist management in identifying and stratifying existing and potential operational issues that impact EmblemHealth’s program from a regulatory perspective. 
  • Work with the department’s management on a day to day basis to implement changes aimed at proactive management of risk areas, provide data and reports that will assist the Director in addressing areas of regulatory risk. 
  • Produce management regulatory reports; assist in resolving regulatory issues; provide regulatory guidance.
  • Responsible for coordinating and ensuring compliant Medicare communications and Part C & D reporting.

 

Responsibilities:

  • Review and interpret Medicare regulatory guidance; review/coordinate Medicare communications and Part C & D reporting; disseminate regulatory guidance to business department for implementation of processes.  
  • Review guidance to identify and stratify existing and potential operational issues that impact EmblemHealth’s products from a regulatory perspective.  
  • Work with the business department management on a day to day basis to implement changes aimed at proactive management of risk areas, provide data and reports that will assist in creating responses to regulatory issues. 
  • Produce routine and ad hoc compliance reports for management as required; assist management in the resolution of regulatory compliance issues, as well as providing regulatory guidance.
  • Monitor product; maintain monthly regulatory scorecard to identify issues and address with business areas for resolution.
  • Lead large scale projects and collaborate efforts for maintenance and development of regulatory program initiatives. 
  • Support the development of regulatory and operational business requirements for ‘best practice’ implementation of Regulatory rules and regulations.  
Qualifications:
  • Bachelor’s degree in Business, Healthcare Administration, or related field
  • 5 – 8 years of relevant, professional work experience (R)
  • 4 – 6 years’ work experience in healthcare operations or regulatory compliance (P)
  • Additional years of experience / specialized training/certifications may be considered in lieu of educational requirements (R)
  • Thorough knowledge of State and/or Federal programs operations and regulations (R)
  • Proficiency in the use of Microsoft Office (Word processing, database/spreadsheet, presentation, Outlook) (R)
  • Attention to detail, analytical and problem-solving skills (R)
  • Proven ability to establish and maintain relationships of trust with departmental staff and management (R)
  • Proven ability to coordinate and lead interdepartmental work teams and meet established goals (R)
  • Must be goal oriented and able to meet tight deadlines while handling multiple priorities (R)
  • Ability to function effectively as a team player and to take direction from multiple sources (R)
  • Must be highly organized, able to handle multiple assignments with competing, overlapping deadlines (R)
  • Ability to communicate clearly and concisely (in writing, verbally, via presentations) to all types/levels of audiences (R) 
  • Ability to arrange work schedule to meet deadlines from multiple sources and engage staff throughout EmblemHealth to assist in the completion of duties (R)
 
 
 

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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