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Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware Job Summary: This position is responsible for the management of regulatory activities across all Medicaid Managed Care Services and Supports Contract and Medicare Special Needs Plan Contract revisions. This role ensures revisions are consistent with Horizon BCBSNJ and Horizon NJ Health mission through the persuasive dissemination of Plan viewpoint and position to State regulators, consumer representatives, community and civic groups, prominent public opinion makers and peer organizations. This position monitors, implements and maintains complete records of all Contract revisions, and keeps appropriate Plan personnel aware of the existence, status, and implementation of all contract amendments. The Specialist will advise and influence business leaders across functional areas and implements regulatory management practices.
Job Responsibilities:
- Maintain expert knowledge of all relevant legislative and regulatory health plan requirements to ensure that plan activities are within contract requirements. Serve as SME on regulations related to Horizons LOBs, contract reporting requirements and required filings.
- Interface with Enterprise leaders and provide direction for operations through consultative support of regulatory contract requirements.
- Identify, evaluate, and recommend solutions to complex contract issues consistent with regulatory requirements.
- Lead regulatory meetings with business teams to discuss matters related to regulatory requirements; oversee and participant in the development of strategies and implementation tactics to protect the Plan's position on pending and current contract revisions.
- Oversee multiple information sources related to changes in regulatory contract requirements for Horizons LOBs; Develop and deploy mechanisms for monitoring information sources.
- Ensure new and revised contract requirements are accurately reviewed, interpreted, summarized, and communicated to the business using multiple distribution methods.
- Independently drive the modification of pending contract revisions and with the drafting of new HNJH proposed contract revisions. Ensure responses are submitted timely and accurately.
- Develops and maintains personal contacts with NJ Department of Human Services staff; serve as point person with state contacts and stakeholders.
- Develop and implement a comprehensive regulatory program that is well designed and executed to ensure regulatory requirements and expectations, including appropriate policies, reporting, training, interpretation, and alignment of contract requirements.
- In partnership with necessary internal operations, develop and provide appropriate responses to inquiries by State regulatory agencies including IPro and annual assessments.
- Oversees implementation of all new Medicaid Managed Care services and supports Contract and Medicare Specials Needs Plan Contract revisions.
- Establishes and maintains positive, collaborative relationships with internal business partners, external regulatory agency representatives and regulatory/compliance consultant groups. Serves as a Horizon point of contact.
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. Education/Experience:
- High School Diploma/GED required.
- Bachelor degree preferred or relevant experience in lieu of degree.
- Requires a minimum of ten (10) years related business experience, preferably within the government health care/insurance industry.
- Clinical experience preferred.
Knowledge:
- Requires understanding of government healthcare programs and insurance industry issues.
- Requires a strong knowledge of the State Contracting process and Medicaid and Medicare requirements.
- Requires knowledge and understanding of state and federal political structure and processes.
- Prefers knowledge of healthcare products and services.
- Prefers knowledge of claims processing.
Skills and Abilities:
- Requires excellent computer skills.
- Requires strong organizational skills.
- Requires ability to elicit cooperation.
- Requires excellent verbal and written communication skills.
- Requires excellent interpersonal skills.
- Requires the ability to work independently.
- Requires the ability to analyze data and formulate relevant reports.
- Requires the ability to analyze and problem solve and report findings in an accurate manner.
Salary Range: $94,900 - $129,570
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:
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
Nov 06, 2024