Managed Care Compliance Specialist - Remote
PMA Companies

Princeton, New Jersey

This job has expired.


As a key member of the Managed Care team, manage all relevant compliance activities and necessary staff to ensure appropriate execution of compliance initiatives, performance improvement across key categories, management of vendor/partner compliance activities, and consistent execution of best practices across functional areas.

Responsibilities:

  • Directs all Managed Care-related compliance activities, including but not limited to fee schedule updates, medical EDI transmissions, certified MCO applications/renewals, custom network (MPN, HCN) approvals, jurisdictional document compliance (EORs, UR letters, panel postings, etc.), bill reviewer and case manager certifications/licensure, PBM formulary compliance, and mandatory managed care state report filings.
  • Plans staff responsibilities and directs activities, utilizing staff resources effectively to meet department goals in accordance with approved plans and budgets.
  • Understands business objectives and utilizes that knowledge to develop and implement compliance policies and procedures to achieve overall corporate goals
  • Interpret complex, technical, professional, regulatory, or legal information and publications distilling into actions as needed
  • Collaborate with other legal, regulatory affairs, and compliance professionals cross-functionally to ensure regulatory and contractual requirements are met
  • Oversees managed care EDI and jurisdictional compliance by maintaining responsibility for EDI troubleshooting, investigation of system-related impacts, and acting as a subject matter expert for EDI enhancements
  • Management of the Managed Care licensing program and development of the long-term objectives for national expansion
  • Oversees vendor/partner compliance activities, licensing and credentialing verification, and works with partners to maintain PMA's regulatory compliance
  • Investigate identified compliance matters, including corrective action and mitigation
  • Evolves reporting and analytics to support ongoing compliance initiatives and to optimize departmental metrics and results
  • Engages in continued learning and understands regulatory and business environment
  • Design and implement a document resource library including copies of current state governing regulations, individual adjuster licensing applications and license copies, and related materials.
  • Promotes effective communication among and between work groups, and between management and employees.
  • Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.


Requirements:
  • Bachelor's degree and/or a minimum of three years of work experience in an insurance or managed care related industry required, preferably in a regulatory, privacy or compliance role.
  • Extensive knowledge of managed care products, workers' compensation regulatory environment and compliance activities.
  • Excellent skills in applying sound judgment/analysis, decision making/problem solving, planning and organization and negotiation.
  • Excellent verbal and written communication skills.
  • Experience in a strategic role, ideally leading and/or implementing a comprehensive compliance program
  • Solid skills in: goal(s) setting and works independently to achieve them. Pushes self and others to reach milestones
  • Advanced knowledge of MS Office Product Suite, i.e. Word, Excel, PowerPoint.


This job has expired.

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