Gateway Health Plan
Job Description :
I. GENERAL OVERVIEW:
This position is responsible for managing the relationships between Gateway HealthSM and Centers for Medicare and Medicaid Services (CMS). The incumbent function 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. Interpreting, confirming and clarifying regulations in order to attain organizational compliance with regulations. Analyzing contractual provisions with CMS and educating Gateway staff regarding Gateway’s expected performance under the Medicare contract including Gateway’s required and prohibited activities. Acting 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. Coordinating 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.
II. ESSENTIAL RESPONSIBILITIES:
1. The incumbent must serve as the primary point of contact with CMS. Acts as the day-to-day manager of contractual and operational issues, coordinating with internal Plan management staff and CMS to facilitate the identification, definition, and 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.
2. The incumbent must serve 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). Coordinates the receipt of and responses to internally generated inquiries related to CMS regulations and policy in a centralized location for staff access.
3. Interprets the information or obtains any clarification that is needed in order to provide appropriate guidance. Continuously monitors regulatory changes, legislative efforts, industry trends, and contract changes and media coverage. Coordinates the receipt and retention of Medicare information related to CMS regulations and policy in a centralized location for staff access. Evaluates the impact on daily business functions, disseminating the information to appropriate GHP management and facilitating any actions necessary for compliance.
4. Medicare Implementation process begins with the release of the Request for Proposal (RFP) from CMS, Gateway’s technical response, county expansion requests to DOH and implementation planning meetings. Each step of this process involves coordination throughout all levels of Plan management under strict deadlines established by CMS and coordinating and replying to any follow-up requests from CMS.
5. Evaluating product material submissions for completeness and compliance with CMS contract requirements, logging submissions into a database, tracking submissions to ensure CMS response, notifying the appropriate management of CMS approval, responding to internal and CMS inquiries regarding submissions, and coordination of rejected submissions.
Coordinates and submits complaint resolutions to CMS in a timely manner. Tracking of complaint resolutions.
6. Designs, delivers and/or documents Medicare-related staff training across the organization in response to any new or revised CMS standards or regulations or required annual trainings.
7. Leads and/or Participates in Medicare Meetings and Workgroups
8. Other duties as assigned or requested.
Education, Licenses/Certifications, and Experience
- High School Diploma (Associate and Intermediate)
- Bachelor degree (Senior and Lead)
- 5-10 years of relevant, progressive experience in the area of specialization
- Bachelor’s Degree (Associate and Intermediate)
- Master’s Degree (Senior and Lead)
- 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
Knowledge, Skills and Abilities
- 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
IV. SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
V. WORK ENVIRONMENT
Is Travel Required?
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