Commercial Regulatory Guidance Specialist

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

Empower. Unite. Care.

MetroPlusHealthis committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

The Commercial Compliance Specialist reports to the Director of Regulatory Compliance. The position will support the oversight and management of QHP, EP, CHP and large group products. This position requires knowledge of healthcare regulations and policies, and the ability to interpret and apply them in a complex and dynamic environment. The Commercial Compliance Specialist will collaborate closely with internal stakeholders to implement policies and procedures, conduct compliance reviews, and provide guidance on compliance matters.

• Ensure compliance with Affordable Care Act, CMS guidelines, and state-specific regulations for marketplace and large group products.
• Provide guidance on compliance matters to internal stakeholders, including senior management, sales and marketing, and product development teams.
• Conduct compliance reviews and audits to identify and address compliance issues.
• Identify compliance risks and contribute to the development of the annual compliance risk assessment and work plan.
• Conduct auditing and monitoring activities as outlined in the compliance work plan.
• Stay up to date on changes in regulations and policies affecting marketplace and commercial products.
• Communicate compliance issues and developments to internal stakeholders, including senior management, sales and marketing, and product development teams.
• Upon identification of non-compliance, provide support to business areas in conducting a root cause analysis and corrective actions, including guidance on methodology, identification of relevant regulatory requirements and any regulatory compliance context and compliance review.
• Plays a critical role in driving the progress for corrective actions throughout the organization.
• Ensures implementation of new policy guidance and regulatory provisions.
• Review supporting implementations, demonstrating compliance with new regulatory provisions.
• Review operational policies and procedures to ensure adherence to regulatory requirements.
• Provides support for full operational external regulatory audits.
• Ensures timely implementation of corrective actions from state regulatory audits.
• Provides updates and data for the materials prepared for both the Internal Compliance Committee Meetings and Audit and Compliance Subcommittee of the Board of Directors.
• Coordinates the support for business areas in creating, updating, and monitoring metrics to assess continued compliance with regulatory requirements.
• Other duties as assigned or requested.

• Bachelor's degree; and
• At least 3 years of managed care experience; or
• A satisfactory combination of education, experience, and training
• CHC, CCEP
• Knowledge of healthcare regulations and policies, including Affordable Care Act, CMS guidelines, and state-specific regulations for government, individual and group insurance policies.
• High-level of skill in leading interdepartmental and cross-functional workgroups; and managing multiple projects to ensure corporate deadlines and objectives are met.
• Ability to operationalize complex regulatory provisions, laws, and statutes.
• Excellent oral, written, and presentation skills, as well as conceptual and analytic skills are necessary to review and articulate corporate objectives and Federal regulations across all relevant audiences.
• The utmost integrity in the discreet and confidential handling of confidential materials is necessary

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

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