Regulatory and Reporting Specialist

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Assist in all components of the Grievance and Appeals (G&A) compliance program for Medicare and Medicaid business lines.

• Take the lead in collaborating with the Compliance department, Auditors, Vendors, and G&A personnel to monitor and ensure adherence to compliance standards.

• Work alongside the Compliance Department and Fraud, Waste, and Abuse teams to assess and mitigate fraudulent activities affecting the G&A Department.

• Carry out internal audits, support external audits, formulate policies and procedures, and guarantee departmental compliance.

• Collaborate with Compliance staff and G&A leadership to create auditing and monitoring plans that evaluate compliance with all State, Federal, and internal regulations.

• Act as a liaison between departments for compliance and FWA initiatives.

• Guide all business operations and workflow decisions to ensure compliance with State, Federal, and internal regulations.

• Stay well-informed and ensure that compliant processes are established for all G&A business operations.

• Keep up-to-date knowledge of all relevant Medicare and Medicaid regulations.

• Conduct regular monitoring of all G&A business operations, disseminate findings, and report to G&A Leadership, Compliance Department, quality committees, and other PacificSource leadership teams as necessary.

• Address all compliance-related inquiries from internal Compliance Department personnel and external Auditors promptly, professionally, and accurately.

⛳️ Requirements

• A minimum of two years of experience in Grievance and Appeals related health insurance is required.

• Preference for candidates with experience in an auditing or compliance role.

• High school diploma or equivalent is mandatory.

• Bachelor’s degree is preferred.

• Proficient computer skills are essential.

• Exceptional verbal and business writing abilities are required.

• Strong public relations skills are necessary.

• A solid understanding of Medical Terminology is required.

• Must possess the ability to identify and prioritize issues and manage workload independently without direct supervision.

🏝️ Benefits

• Flexible telecommuting policy.

• Medical, vision, and dental insurance coverage.

• Incentive program available.

• Paid time off and holidays.

• 401(k) retirement plan.

• Opportunities for volunteering.

• Tuition reimbursement and training support.

• Life insurance options.

• Flexible spending account options available.