To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship by: managing the Government Programs department to meet the needs of internal customers and requirements of regulatory agencies.  This includes serving as point of contact for the Office of Insurance Regulation (OIR) and Centers for Medicare and Medicaid Services (CMS) and (in coordination with Legal and Compliance) delivery of accurate, clear communication to interpret State statutes and Federal regulations. Facilitates executive level meetings, is proactive in presenting regulatory information in a clear and concise manner and implementing solutions to support internal compliance activities with the Health Plan.  The Director has ultimate responsibility for partnering with Corporate Compliance in an effective and engaging manner.

Primary Accountabilities: 

• Works closely and effectively with the Corporate Compliance, Legal Counsel and HFHP executive and department leadership teams.
• Available to all associates, members and visitors for consultation regarding regulatory matters or concerns.
• Provides regular reporting and communication to executive leadership and team members regarding top concerns, areas of risk, regulatory changes and impacts.
• Responsible to manage and develop an engaged team to support delivery of a high performing regulatory program as measured by CMS and OIR program requirements.
• Establishes current and long range objections, plans and policies in support of the VP of direct report and Chief Compliance Officer.
• Manages, coordinates and oversees audits, site visits and internal regulatory issues as it related to OIR, AHCA, CMS and other regulatory, government agencies.
• Responsible for development and oversight of an internal audit function within the Health Plan.
• Responsible for State and Federal regulatory activities, ensuring plan activities are compliant with all applicable laws, regulations, rules and policies.
• Monitors, researches and disseminates applicable regulatory and business requirements ensuring timely implementation to any new laws and regulations.
• Serves as internal resource for regulatory and contract interpretations, critically analyzing implications and making appropriate recommendations for operational or policy/process changes.
• Coordinates and responds to issues or requests around government, State and Federal rules and regulations as well as new products and programs.
• Builds and maintains a source of reference material, manuals, and files responding accurately to State and Federal action items within required timeframes.
• Contributes to the professional delivery of compliance program work products in a timely and appropriate manner.
• Ensures that the plan meets the CMS and OIR program requirements by monitoring internal and external regulatory compliance.  Responsible for detecting, analyzing and remediating any potential or actual regulatory issues.
• Serves as primary contact and liaison for all state and federal agencies, effectively communicating HFHP’s position to regulators.
• Works across departments to drive improvements in customer experience and company performance. Conducts special studies/projects as requested by Senior Management to identify opportunities for improvement consistence with Health First’s strategic goals.
• Facilitates timely submission of the annual Medicare Bid to CMS and form and rate filings with the OIR.  Works with Actuary, CMS and OIR to gain approval of the filings as appropriate.
• Prepares and manages department budget.
• Directs the establishment and maintenance of a process for implementing new and validating compliance with existing regulatory and statutory requirements. Provides Corporate Compliance with updates as necessary.
• Oversees regulatory compliance with the Affordable Care Act (ACA) for products on and off the Marketplace.

Qualifications

• Four-year degree from accredited college/university required
• Five to eight years of health care compliance and/or regulatory program experience
• Knowledge of Medicare and managed care contracts required
• Experience in initiating, developing and monitoring policies, internal control
• Proficient in Microsoft Office applications
• Proficient in public speaking, conflict resolution and data management
• Superior written and oral communication skills
• Superior interpersonal relationship skills

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