Job Summary:The Regulatory Affairs Director is responsible for leading activities of the Regulatory Affairs Department, including contracts, compliance, surveys, audits, investigations, reporting, plan development and renewal, credentialing, Fraud, Waste & Abuse Special Investigations, provider network and relations, regulatory updates and compliance matters.
Essential Functions:- Review, draft, negotiate and process agreements and amendments in accordance with organization guidelines.
- Lead projects involving the collection and submission of data and information related to government audits, surveys and requests.
- Oversee provider contracting, including letters of agreement and associated follow-up.
- Review, disseminate and handle fair hearing (FH) notices and decisions; manage FH calendar; attend FHs as needed, review and handle communications with OTDA and submit reports; prepare status reports and updates on cases.
- Lead activities of the Special Investigation Unit (SIU), including SIU reporting and internal investigations.
- Review and update applicable HIPAA policies and procedures in compliance with HIPAA laws and regulations.
- Review OIG/OMIG requirements and best practices for compliance and program integrity; review and update compliance materials, including manuals, policies and procedures, and handbooks, to comply with regulatory requirements.
- Make recommendations based on best practices and draft policies and procedures.
- Review DOH and CMS plan contracts and edit plan documents in compliance with contract requirements.
- Review, clarify and disseminate CMS memos and DOH guidance; keep abreast of related laws, regulations and official guidance.
- Coordinate document and requests of outside counsel for litigation matters.
- Oversee provider credentialing process and related activities.
- Draft policies, procedures, manuals, plan and member materials.
- Provide guidance and direction to Department staff.
- Perform any other job related duties as requested.
Education and Experience:- Juris Doctor (J.D) degree from an accredited college/university required
- Five (5) years experience with Medicare and NY Medicaid managed care contracting and compliance required
- Previous leadership experience preferred
Competencies, Knowledge and Skills:- Strong customer service and team orientation
- Ability to adapt to a changing environment to achieve results
- Demonstrated leadership skills
- Skilled in organization, workflow analyses and management of details
- Advanced Microsoft Office skills, including Word
- Strong editing and proofreading skills
- Excellent written and oral communications skills
- Excellent time/project management and prioritization skills
- Ability to excel in fluid, dynamic environment
Licensure and Certification:- Current, unrestricted Attorney license required
Working Conditions:- General office environment; may be required to sit or stand for extended periods of time
- Ability to travel as required by the needs of the department.
- 2 Days work from home; 3 days work in Bronx office each week
Compensation Range:$135,600.00 - $237,400.00
CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary): Salary
Organization Level Competencies - Fostering a Collaborative Workplace Culture
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business
