Medicare Regulatory Specialist


Farmington, CT

Industry: Healthcare


5 - 7 years

Posted 43 days ago

Job Description

ConnectiCare is a leading health plan in the state of Connecticut. ConnectiCare’s mission is to make it easy for members to get the care they need. A local company for over 35 years, ConnectiCare has a full range of products and services for businesses, municipalities, individuals and those who are Medicare-eligible. A subsidiary of EmblemHealth, ConnectiCare leads the individual and small group markets in the state, and is ranked among the top commercial health plans in the nation, according to the National Committee for Quality Assurance.

We’re looking for individuals who want to make a difference in the communities we serve. If you want to join a local team and help change the way health care is delivered, ConnectiCare is the place for you.

Purpose: Work with designated operational departments to implement Medicare regulations and ensure continued compliance while optimizing business processes. The Medicare Regulatory Specialist will collaborate with Medicare Compliance personnel on interpretation of Medicare guidelines and use their operational and regulatory knowledge to facilitate implementation of requirements for applicable operational departments, test for compliance and monitor business processes. This position will work with the Director of Medicare Regulatory Implementation and Coordination to implement new requirements, review current business processes, identify deficiencies, monitor operations and provide reporting on existing and potential issues. Key Accountabilities will be divided amongst specialists based on organizational structure.

Key Accountabilities:

  1. Collaborate with Compliance department on interpretation of Medicare regulations.
  2. Review and monitor CMS guidelines and collaborate with business areas to implement.
  3. Work with business areas to identify possible compliance or operational risks and provide reporting to MRIC Director.
  4. Monitor business processes and Policies and Procedures to ensure compliance with requirements.
  5. Prepares and maintains documentation of MRIC implementation projects.
  6. Maintain MRIC tracking logs and databases.
  7. Manage Medicare material review and submission process.
  8. Marketing Incident investigations, process management and reporting.
  9. Coordinate Part C & D reporting process including reviewing requirements with business areas and upload/entry to HPMS.
  10. Assist business areas with Part C & D reporting Data Validation process.
  11. Review internal Secret Shopping program results and provide reporting.
  12. Monitor dashboards to identify areas of concern.
  13. Other duties as necessary.

Required Skills

Technical Knowledge and Experience:

  1. Bachelor's degree in Business Administration or related area or equivalent experience.
  2. At least 5 years’ experience in managed care operations and/or compliance preferably with some Medicare experience
  3. Ability to interpret Federal and State laws and regulations.
  4. Strong interpersonal, organizational, analytical, project management, problem solving and leadership skills
  5. Demonstrated ability to manage several complex projects simultaneously
  6. Strong written and oral communications skills a must as this position must able to effectively and appropriately communicate with Federal and State Regulators, internal personnel and ConnectiCare members