Company :Highmark Wholecare
Job Description :
This job manages the relationships between Gateway HealthSM and Centers for Medicare and Medicaid Services (CMS). The incumbent functions as the primary contact with CMS and other Government agencies (i.e. Department of Public Welfare, and any related state or federal agency) for regulatory issues related to Medicare. Interprets, confirms, and clarifies regulations in order to attain organizational compliance with regulations. Analyzes contractual provisions with CMS and educates Gateway staff regarding Gateway’s expected performance under the Medicare contract including Gateway’s required and prohibited activities. the incumbent acts as a liaison that professionally represents Gateway’s business interests, on a wide variety of issues, in order to accomplish the mission and goals set forth by Gateway’s management. Coordinates requests for CMS approval. Designs, delivers and/or documents Medicare-related staff training across the organization in response to any new or revised CMS standards or regulations. Coordinates the receipt and retention of Medicare information related to CMS regulations and policy in a centralized location for staff access. Coordinates RFP process including submission to CMS for product expansion.
- Primary point of contact with CMS.
- Act as the day-to-day manager of contractual and operational issues.
- Coordinate with internal Plan management staff and CMS to facilitate the identification, definition, solving of complex business problems and implement corrective action when necessary, thereby ensuring compliance. Contacts include legislators, consumers, special interest groups, advocacy agencies, CMS and other regulatory bodies such as DPW.
- Act as a resource to research and respond to internal management questions. Research includes reviews of various Internet websites including the Centers for Medicare and Medicaid Services (CMS), Federal Register, Pennsylvania Code, Department of Health (DOH), US Census Bureau, Food and Drug Administration (FDA) and the Pennsylvania Power Port, as well as other resources such as CMS contracts and Requests for Proposal (RFPs).
- Coordinate the receipt of and respond to internally generated inquiries related to CMS regulations and policy, in a centralized location, for staff access.
- Interpret the information or obtains any clarification that is needed in order to provide appropriate guidance.
- Continuously monitor regulatory changes, legislative efforts, industry trends, and contract changes and media coverage.
- Coordinate the receipt and retention of Medicare information related to CMS regulations and policy, in a centralized location, for staff access.
- Evaluate the impact on daily business functions, disseminate the information to appropriate GHP management and facilitate any actions necessary for compliance.
- Manage the Medicare Implementation process that begins with the release of the Request for Proposal (RFP) from CMS, Gateway’s technical response, county expansion requests to DOH and implement planning meetings. Coordinate each step of this process throughout all levels of Plan management under strict deadlines established by CMS and reply to any follow-up requests from CMS.
- Evaluate product material submissions for completeness and compliance with CMS contract requirements, log submissions into a database, track submissions to ensure CMS response, notify the appropriate management of CMS approval, respond to internal and CMS inquiries regarding submissions, and coordinate rejected submissions.
- Coordinate and submit complaint resolutions to CMS in a timely manner.
- Track complaint resolutions.
- Design, deliver and/or document Medicare-related staff training across the organization in response to any new or revised CMS standards or regulations or required annual training.
- Lead and/or participate in Medicare Meetings and Workgroups.
- Other duties as assigned or requested.
- Bachelor degree
- 5-10 years of relevant, progressive experience in the area of specialization
- Master's Degree
- Experience in one or more of the following: healthcare operations, healthcare regulations, working directly with regulatory agency(ies), compliance, managed care operations, and/or process improvements
- Strong written and oral communication skills.
- Strong relationship building skills.
- Self-starter with the ability to work under pressure independently and as part of a team.
- Strong problem-solving capabilities
- Demonstrated ability to effectively interact with all levels within the organization.
- Proficiency with Microsoft Office software programs
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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