The Regulatory Specialist is responsible for promoting compliance with regulatory requirements with Healthfirst's Utilization Management, Care Management, Appeals and Grievance, or Pharmacy departments and/or delegated vendors. Compliance is promoted ensuring regulatory updates are evaluated, implemented and by performing monitoring to evaluate compliance with regulatory requirements required by, Centers for Medicare and Medicaid Services (CMS) and State Department of Health (DOH) regulations, and business requirements.
Description- Meets with the Regulatory department to organize pre-survey deliverables and conduct reviews of materials.
- Interacts with and represents the business unit.
- Responds to auditor requests and audits outcome results.
- Identifies organizational risks and helps implement process improvements.
- Manages, coordinates, and participates in the implementation of contract changes for all lines of business pertaining to Utilization Management/Care Management/Appeals & Grievances departments.
- Ensures that all process and contract changes are reflected in departmental policies and procedures.
- Reviews Healthfirst policies, procedures, and correspondence to ensure compliance with CMS and DOH regulations
- Monitors all Utilization Management/Care Management/Appeals & Grievances corrective action plans (CAPs) through completion.
- Reviews timeliness of all Utilization Management/Care Management/Appeals & Grievances monitoring reports to assess for compliance with regulatory time frames and develops CAPs if non-compliance is observed.
- Assists in accreditation submissions, regulatory surveys, and internal audits.
- Additional duties as assigned
Description for Regulatory Specialist providing support to Pharmacy and the Pharmacy Benefit Manager (PBM)- Monitor incoming regulations including those received from Centers for Medicare and Medicaid Services (CMS), State Department of Health (DOH), PBM and internal channels.
- Share regulatory guidance with Pharmacy department and provide support to ensure regulation and impact are understood. Act as a liaison between Pharmacy Department and Regulatory Affairs/Legal when guidance on interpretation is required.
- Provide support to Pharmacy Department related to regulatory implementation efforts including:
- Tracking deliverables to target
- Coordinating meeting and collecting deliverables from business units.
- Capturing action steps
- Communicating to leadership
- Perform monitoring of timeliness of decision-making and notification compliance standards to ensure adherence with CMS and DOH regulations. This includes coverage determinations and appeals.
- Perform monitoring of written notifications for coverage determinations and appeals to ensure compliance with CMS and DOH regulations. This includes appropriate letter template usage and assessment of adequate rationales with correct/complete information is language easily understandable by enrollees.
- Perform monitoring of Medicare Part D grievances to ensure appropriate classification, thorough investigation and response provided to all grievances raised.
- Performing monitoring of coverage for drugs that may not be covered under Medicare Part D to ensure compliance with CMS requirements. This includes but is not limited to:
- Drugs used for symptom control or pain relief related to a terminal illness for hospice eligible beneficiaries,
- Nebulizer drugs used with an item of durable medical equipment
- Immunosuppressive drugs with evidence of a Medicare covered transplant
- Drug categories that are "always" considered to be End-Stage Renal Disease (ESRD) related when furnished to an ESRD patient; and
- Prescription drug event records for Adcirca, Revatio and Cialis without a documented medically accepted indication under Medicare Part A, Part B or Part C programs
- Monitor PBM to ensure timely sharing of complaints and grievances received for non-Medicare lines of business.
- Maintain dashboard to track monitoring results including areas of non-compliance and process improvements for discussion with PBM and Pharmacy leadership.
- Identify process gaps or process improvements and collaborate with Pharmacy department and other business units to implement process enhancements.
- Assist with creating corrective action plans.
- Attend Regulatory, Pharmacy and departmental meetings, as deemed appropriate.
- Additional duties as assigned.
Minimum Qualifications:- High School Diploma or GED.
Preferred Qualifications:- Bachelor's degree from an accredited institution.
- Previous relevant compliance experience.
- Proficiency with Microsoft systems like Outlook, Excel, and Word.
Minimum Qualifications for Regulatory Specialist providing support to Pharmacy and the Pharmacy Benefit Manager (PBM)- High school diploma or equivalent with at least four (4) years of health care experience
- Strong knowledge of CMS and/or New York State DOH regulations. Compliance experience within a managed care environment.
- Working knowledge of project management
- Intermediate MS Word, Excel, PowerPoint, Adobe Acrobat and corporate email systems
- Ability to build and maintain positive relationships with cross-functional teams and interact with all levels of management.
- Time management, critical/creative thinking, project management, communication, and problem-solving skills
Preferred Qualifications for Regulatory Specialist providing support to Pharmacy and the Pharmacy Benefit Manager (PBM)- Bachelor's degree preferred in related field.
- Relevant previous work experience and knowledge of Department of Health (DOH) and Local Department of Social Services and Center for Medicare & Medicaid Services (CMS) regulations pertaining to managed care; etc.
Hiring Range*:
- Greater New York City Area (NY, NJ, CT residents): $68,900 - $99,620
- All Other Locations (within approved locations): $61,300 - $89,440
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
*The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.
