Regulatory and Reporting Specialist

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PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

⚕️ Healthcare Insurance

💸 Finance

🧘 Wellness

Healthcare Insurance • Finance • Wellness

PacificSource Health Plans is a healthcare provider that offers a range of health insurance solutions, including plans for individuals, families, and employers. Their offerings include Medicare and Medicaid plans, dental coverage, and administrative services for small and large groups. Committed to member care, PacificSource emphasizes customer service and provides various resources for health management, including mental health support and wellness programs.

📋 Description

• Support all aspects of the Grievance and Appeals (G&A) compliance program for Medicare and Medicaid lines of business • Assume the primary role of interfacing with the Compliance department, Auditors, Vendors and G&A staff for purposes of monitoring and ensuring compliant operations • Interface with the Compliance Department and Fraud, Waste and Abuse teams to evaluate and address fraudulent activities impacting the G&A Department • Conduct internal audits, support external audits, develop policies and procedures, and ensure departmental compliance • Develop auditing and monitoring plans to assess compliance with all State, Federal and internal business rules and regulations • Serve as an inter-departmental liaison for compliance and FWA activities • Inform all business operations and workflow decisions to ensure that programs are compliant with State, Federal and internal business rules and regulations • Be fully informed and ensure compliant processes are in place on all G&A business operations • Conduct frequent monitoring activities of all G&A business operations, publish results and report out to G&A Leadership, Compliance Department, quality committees and other PacificSource leadership teams as applicable • Respond to all compliance related inquiries from internal Compliance Department Staff and external Auditors

🎯 Requirements

• Minimum of two years of Grievance and Appeals related health insurance experience required • Strong preference for experience in auditing or compliance related role • High school diploma or equivalent required; Bachelor's degree preferred • Strong computer skills • Excellent verbal and business writing skills • Excellent public relations skills • Good understanding of Medical Terminology required • Requires ability to define and prioritize problems and manage workload without direct supervision

🏖️ Benefits

• Flexible telecommute policy • Medical, vision, and dental insurance • Incentive program • Paid time off and holidays • 401(k) plan • Volunteer opportunities • Tuition reimbursement and training • Life insurance • Options such as a flexible spending account