Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

The Regulatory Compliance Associate is responsible for the identification and communication of new, revised, and pending federal and state laws, regulations, and standards relevant to a Horizon Lines of Business (LOB). This position administers and coordinates the functions associated with compliance and regulatory guidelines related to each market and will develop and maintain standard operating policies and procedures, compliance reporting and dashboards, and execute the annual Compliance workplan. This position will work with business to ensure compliance with relevant agencies including but not limited to: Centers for Medicare & Medicaid Services (CMS), Division of Medical Assistance and Health Services (DMAHS), Get Covered New Jersey and The New Jersey Department of Banking and Insurance (DOBI). Regulatory Compliance Associates collaborate with internal divisions to foster a compliant culture and ensure regulatory compliant materials and activities.Responsibilities:

• Maintain knowledge of all relevant legislative and regulatory health plan requirements and monitor information sources for changes in regulatory compliance program requirements for Horizon's LOBs.

• Analyze information and determine what is informational versus change affecting organizational processes.

• Review, interpret, summarize and communicate new and revised requirements to the business unit personnel using multiple distribution methods.

• Provide plain language compliance guidance and direction to operationalize regulatory compliance requirements and support implementation of changes stemming from new or revised State and Federal requirements.

• Oversee compliance with new, revised, and pending regulatory requirements through the Requirements Database, and collect and evaluate evidence of compliance submissions from business unit personnel.

• Support and actively participate in annual team functions including monitoring, ongoing risk assessment, audit readiness activities, external audit coordination, executing the compliance workplan, and other divisional priorities related to risk mitigation.

• Gather relevant data and Key Performance Indicators for compliance reports and dashboards, and prepare reports based on established reporting metrics for the group.

• Independently investigate areas of non-compliance, and act on matters by designing and coordinating internal investigations and resulting corrective action plans with all departments.

• Identify potential non-compliance vulnerabilities and make practical business recommendations to correct non-compliance or improve insufficient processes.

• Monitor business units' self-monitoring results to ensure that current procedures satisfy regulatory requirements and are sufficient to detect future instances of non-compliance. Assist with the development of compliance policies, control processes, self-monitoring, and self-auditing tools that promote maintaining compliant business processes.

• Develop and update Standard Operating Policies and Procedures (SOP) for review processes and compliance. Educate stakeholders on these SOPs.

• Develop collaborative relationships with regulators. Monitor compliance related commitments made to regulatory agencies governing Horizon's LOBs, and review and maintain submissions, reports, and filings to regulators.

Addendum (Medicare):

• Actively participates in the annual product implementation, including providing guidance on and facilitating review and approval of all materials related to product implementation (i.e. annual notices of change, evidence of coverage documents, formulary and provider related material and model operational letters).

• Serve as a subject matter expert on the CMS (Center for Medicare & Medicaid Services) Medicare Marketing Guidelines (MMG) for Horizon's Medicare products. Establish and maintain a comprehensive understanding of all CMS and State requirements related to Medicare Advantage, Medicare Part D and Medicaid requirements, for the special needs plan, with respect to marketing and related materials.

• Develop and maintain tools to facilitate and report on the internal review of materials (e.g. internal CMS Submission Database; SharePoint site functionality) consistent with evolving CMS and DMAHS marketing guidelines.

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 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:

• Knowledge of the sources of legal and regulatory requirements relevant to state and federal requirements.

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.

Travel:

Travel to other office locations may be required.

Salary Range:

$84,700 - $115,605

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:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

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.