Compliance Manager

📋 Description

• Monitor and evaluate both state and federal regulatory changes, legislation, and industry trends that impact workers' compensation within Rising’s business sectors.

• Conduct independent research, track, and assess the regulatory effects on managed care, bill review, and timely payment operations.

• Relay updates on regulatory modifications to internal teams and clients.

• Contribute insights and expertise in creating corporate compliance training materials.

• Assist clinical operations to uphold and support URAC certification and reaccreditation.

• Oversee certified managed care programs (MPN/MCO), which includes state filings, renewals, amendments, and reporting.

• Act as the primary liaison with state regulatory bodies concerning filings, audits, deficiencies, and inquiries.

• Spearhead the implementation and launch of customer managed care programs.

• Maintain historical archives and resource documentation for state filings and client materials.

• Provide assistance for state UR certification processes, including renewals and compliance monitoring, as well as URAC certification.

• Create and sustain managed care resource materials for Rising's state filings and customer worksite documentation.

• Oversee the coordination of resources to ensure the continuous effectiveness of state managed care programs.

• Monitor state regulatory sources for provider suspensions, exclusions, arrests, and fraud-related actions that impact workers’ compensation participation.

• Direct the validation of provider TIN/NPI data, ensuring fraud flags are logged in Vision, and supervise timely notifications to bill review and utilization review teams when risks are identified.

• Lead and manage the MPN Coordinator team, ensuring a consistent application of MPN rules, compliance standards, and service expectations.

• Oversee provider compliance, including credentialing changes, suspensions, fraud monitoring, and continuity of care.

• Monitor the distribution of workload and completion of MPN scheduling tasks to ensure service level expectations are fulfilled.

• Provide coaching and performance oversight to facilitate timely and accurate responses to MPN inquiries from injured workers, clients, adjusters, and attorneys.

• Review geographic access analyses and direct corrective measures to address network coverage deficiencies; serve as an escalation point and backup responder as necessary.

• Maintain regulatory documentation, dashboards, trackers, and compliance materials.

• Assist with RFP responses concerning managed care, bill review, timely payment, and regulatory compliance.

• Manage cross-functional projects through planning, research, implementation, and audit review.

• Support the upkeep of Business Continuity Plans and Disaster Recovery Plans, ensuring they are updated.

⛳️ Requirements

• A Bachelor's degree in business administration or a related field, along with ten (10) years of substantial business experience, or ten (10) years of relevant industry experience.

• Extensive experience in researching and interpreting state managed care plans and medical bill review requirements for Workers' Compensation.

• Demonstrated ability to handle multiple projects and deadlines effectively in a regulated environment.

• Experience collaborating with regulatory agencies, customers, and internal operational teams.

• Capability to interpret legislation and convert regulatory requirements into operational directives.

• Exceptional attention to detail, planning, and follow-through skills.

• Strong critical thinking and problem-solving abilities.

• Must be a self-motivated individual, adaptable, customer-focused, and maintain a professional demeanor.

• Ability to work both independently and collaboratively as part of a team.

• Knowledge of industry regulations, terminology, principles, and practices; familiarity with legal reference materials, and a comprehensive understanding of research methods.

• Proficiency in Microsoft Office applications, SharePoint, and Office 365.

• Excellent verbal and written communication capabilities.

• Strong organizational and time management skills.

• Experience in drafting briefs and/or position papers.

🏝️ Benefits

• Health insurance (with four different plans available).

• Dental coverage.

• Vision insurance.

• Paid time off (PTO) or Flexible Time Off (FTO).

• 401(k) retirement plan.

• Basic Life Insurance and Long-Term Disability Insurance (covered by the company).

• Optional Life Insurance and Short-Term Disability Insurance.

• Flexible Spending Accounts (FSA).

• Employee Assistance Program (EAP).

• Rise Well Wellness Program.

• Professional Development Reimbursement Program (PDRP).

• Participate in our new Elevate program designed to acknowledge and reward employees for their hard work.

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