PacificSource
Care Management Regulatory and Reporting Specialist (Monday - Friday)
PacificSource, Springfield, Oregon, us, 97475
Looking for a way to make an impact and help people?
Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Support all aspects of Care Management regulatory compliance for the Government LOB's by assuming a primary role of interfacing with the Compliance department, Auditors, Vendors and Health Services staff for purposes of monitoring and ensuring compliant operations. Conduct internal audits, support external audits (including subcontractors) and collaborate with internal stakeholders to ensure departmental compliance.
Essential Responsibilities: In partnership with Health Services leadership and Compliance, develop and conduct internal audits to assess and ensure compliance with Federal, State, organizational, and industry rules, regulations, and standards; Serve as an inter-departmental liaison for compliance. Monitor all CM operations and workflow decisions to ensure that programs are compliant with the applicable regulatory requirements and internal business rules and regulations. Maintain a current working knowledge of all applicable regulatory requirements including assessment, impact report and training on any new rules or regulations. In collaboration with Health Services leadership and the Quality and Regulatory Affairs team, respond to compliance related inquiries from internal Compliance staff and external Auditors in a timely, professional and accurate manner to ensure minimal organizational and operational impact. Work collaboratively with Health Services leadership to produce and monitor department policies and procedures as applicable and ensure regular maintenance to reflect new practices and guidance. Provide interpretation, training, and implementation of CM regulatory requirements regulations and communicate them appropriately with respective LOB and teams. Support ongoing communication efforts. Maintaining compliant member, Health Services and provider communications by keeping letters and other member communications up to date with compliance guidance and best practices. Supporting Responsibilities:
Meet department and company performance and attendance expectations. Serve on designated committees, teams, and task groups, as directed. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information. Perform other duties as assigned. Work Experience:
Minimum of four years of CM related health insurance experience required. Strong preference for experience in auditing or compliance related role. Other relevant work experience.
Education, Certificates, Licenses:
High school diploma or equivalent required. Bachelor's or Associates degree preferred.
Knowledge:
Strong computer skills, including Microsoft Office, with demonstrated proficiency in Excel. Excellent verbal and business writing skills. Must be detail oriented. Excellent public relations skills. Good understanding of Medical Terminology required. Requires ability to define and prioritize problems and manage workload without direct supervision. Basic project management skills are essential.
Competencies:
Adaptability
Building Customer Loyalty
Building Strategic Work Relationships
Building Trust
Continuous Improvement
Contributing to Team Success
Planning and Organizing
Work Standards
Environment:
Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork
Our Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
We are committed to doing the right thing. We are one team working toward a common goal. We are each responsible for customer service. We practice open communication at all levels of the company to foster individual, team and company growth. We actively participate in efforts to improve our many communities-internally and externally. We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community. We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements:
Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer:
This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Support all aspects of Care Management regulatory compliance for the Government LOB's by assuming a primary role of interfacing with the Compliance department, Auditors, Vendors and Health Services staff for purposes of monitoring and ensuring compliant operations. Conduct internal audits, support external audits (including subcontractors) and collaborate with internal stakeholders to ensure departmental compliance.
Essential Responsibilities: In partnership with Health Services leadership and Compliance, develop and conduct internal audits to assess and ensure compliance with Federal, State, organizational, and industry rules, regulations, and standards; Serve as an inter-departmental liaison for compliance. Monitor all CM operations and workflow decisions to ensure that programs are compliant with the applicable regulatory requirements and internal business rules and regulations. Maintain a current working knowledge of all applicable regulatory requirements including assessment, impact report and training on any new rules or regulations. In collaboration with Health Services leadership and the Quality and Regulatory Affairs team, respond to compliance related inquiries from internal Compliance staff and external Auditors in a timely, professional and accurate manner to ensure minimal organizational and operational impact. Work collaboratively with Health Services leadership to produce and monitor department policies and procedures as applicable and ensure regular maintenance to reflect new practices and guidance. Provide interpretation, training, and implementation of CM regulatory requirements regulations and communicate them appropriately with respective LOB and teams. Support ongoing communication efforts. Maintaining compliant member, Health Services and provider communications by keeping letters and other member communications up to date with compliance guidance and best practices. Supporting Responsibilities:
Meet department and company performance and attendance expectations. Serve on designated committees, teams, and task groups, as directed. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information. Perform other duties as assigned. Work Experience:
Minimum of four years of CM related health insurance experience required. Strong preference for experience in auditing or compliance related role. Other relevant work experience.
Education, Certificates, Licenses:
High school diploma or equivalent required. Bachelor's or Associates degree preferred.
Knowledge:
Strong computer skills, including Microsoft Office, with demonstrated proficiency in Excel. Excellent verbal and business writing skills. Must be detail oriented. Excellent public relations skills. Good understanding of Medical Terminology required. Requires ability to define and prioritize problems and manage workload without direct supervision. Basic project management skills are essential.
Competencies:
Adaptability
Building Customer Loyalty
Building Strategic Work Relationships
Building Trust
Continuous Improvement
Contributing to Team Success
Planning and Organizing
Work Standards
Environment:
Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork
Our Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
We are committed to doing the right thing. We are one team working toward a common goal. We are each responsible for customer service. We practice open communication at all levels of the company to foster individual, team and company growth. We actively participate in efforts to improve our many communities-internally and externally. We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community. We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements:
Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer:
This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.