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Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
The Regulatory Compliance Associate is responsible for the coordination and execution of required Medicare Part C and Part D reporting obligations; and the related annual data validation audit in accordance with CMS requirements, including managing the contracted external audit firm. Responsible for developing and updating the internal governance process for CMS reporting to reflect compliance with applicable CMS technical requirements. This includes interfacing with internal and external business partners, as well as providing direction and training on CMS guidelines and data validation processes. This position also coordinates other audits of the Medicare Advantage and Part D business which may be conducted by CMS, OIG, DMAHS or other external entities. In addition, develops standard operating tools and processes to support the successful outcome of these audits and the efficient use of enterprise resources.
Responsibilities:
Develops and maintains Standard Operating Policies and Procedures (SOPs) and tools to support compliance with CMS reporting requirements and related audits. Educates internal and external stakeholders and report owners on the requirements. This includes developing and maintaining the internal governance process related to Part C and D reporting and the documentation to support the annual data validation audit. Serves as the primary subject matter expert on the CMS Part C and D reporting requirements and related annual data validation audit. Reviews, interprets and communicates CMS guidelines and regulations specific to Medicare Part C and D reporting requirements, the related CMS reporting technical specifications and CMS data validation procedures. Review and implement new and revised CMS technical reporting requirements with business owners. Solicit internal feedback on draft CMS requirements related to reporting and audits and provide feedback to CMS and/or trade associations so that Horizon-s position is considered. Review and implement changes to Horizon-s data validation processes and documentation to reflect changes in CMS requirements. Submit Part C and D reports to CMS accurately and on time. Develops an annual reporting schedule and tracks and reports on status of report submissions to CMS. Manage and coordinate the annual data validation contracted audit firm(s) engagement including the contracting, remediation and audit phases. Coordinate CMS data validation audit and other external audits and ensure all requests and deliverables are provided to the auditors on a timely basis. Develop and maintain workplans to identify and support the work required to execute on audits and to address any gaps and risks. Coordinate responses to audit reports and ensure corrective action plans are developed and executed for audit findings. Interface across multiple functional areas and internal/external business partners, as a subject matter expert (SME) by providing operational, analytical and consultative assistance in support of external audits. Facilitate efforts with internal and/or external report/data owners with respect to ensuring their work instructions are kept up to date and that they sufficiently detail their processes as required in order to ensure compliance with CMS requirements. Develop and maintain collaborative relationships with CMS regulators and auditors in support of Horizon government programs business objectives. esponsible for audit readiness and audit completion activities related to Braven Medicare Advantage (including but not limited to annual Part C/D Data Validation Audit, Timeliness Monitoring Project Audit, CMS Program Audits, CMS Financial Audits, CPE Assessments, and subsequent Validation Audits). Coordinate the scheduling of audit webinars, consultant communications as it pertains to audits, quality assessment of data and universe tables during audits and mock audits, and implementation and monitoring of CAPs that originate due to audit findings. Develop and maintain processes and workflows as it relates to Braven Health MA Compliance to ensure all data and CAPs are separate and distinct from Horizon. - Ensure applicable Horizon MA workflows are followed for Braven Health MA, and compliance requests from Braven Health are carried out timely.
Education/Experience:
High School Diploma/GED required. Bachelor's degree preferred or relevant experience in lieu of degree. Requires a minimum of five (5) years of relevant compliance experience in a healthcare or managed care environment. Requires a minimum of three (3) years' experience in the interpretation and application of federal and state regulations, policies and procedures, and ethical principles related to healthcare compliance.
Additional Licensing, Certifications:
Preferred Certifications:
Certified Compliance & Ethics Professional Certification (CCEP) - Compliance Certification Board Certified in Healthcare Compliance (CHC) - Compliance Certification Board Leadership Professional in Ethics & Compliance (LPEC) - Ethics and Compliance Institute
Knowledge:
Medicaid:
Knowledge of the Federal and State regulatory environment in the health insurance industry, with emphasis on Medicaid and NJFamilyCare, Managed Long-Term Services and Supports, the New Jersey False Claims Act, Fraud, Waste and Abuse, Anti-Kickback law and State Medicaid requirements.
Commercial:
Knowledge of the Federal and State regulatory environment in the health insurance industry, with emphasis on state and federal mandates, health insurance exchanges, qualified health plans, and the Affordable Care Act. Understanding of compliance issues and healthcare risk areas applicable to Commercial insurance.
Medicare:
Knowledge of state and federal laws and regulations, including CMS, DOBI and DMAHS requirements. Knowledge of CMS regulations, including Medicare Marketing guidelines.
Skills and Abilities:
Excellent at organizing, managing, and handling competing projects with a proven ability to meet tight deadlines in a fast-paced environment. Skilled at managing a high volume of work with changing priorities and frequent interruptions while maintaining the ability to work cooperatively with a positive attitude. Written and oral communication. Facilitation, active listening, and presentation skills. Critical thinking skills and the ability to apply an analytical approach to regulatory research and issue remediation. Persuasion/negotiation and interpersonal relationship skills and the ability to effectively interact and collaborate with individuals at all levels within the organization. Problem solving acumen. Ability to identify potential noncompliance issues, obtain information to clarify and describe issue, exercise sound decision-making, resolve problems using appropriate risk treatment, and leverage appropriate escalation pathways. High degree of discretion in dealing with the confidentiality of all compliance-related issues.
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware Salary Range: $86,000 - $117,390
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
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 this job. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
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Horizon Blue Cross Blue Shield of New Jersey
tuition reimbursement
Feb 20, 2025