Resp & Qualifications
This position will work in collaboration with the Manager of Risk & Regulatory Compliance in coordinating internal audits; conduct regular review and audit of internal controls within each functional area for strengths and weaknesses ensuring special focus allocation to the specific risk areas creating the highest exposure. Coordinate the follow-up process for audit findings; develop and implement a corrective action plan for any areas identified as risk exposure. Provide regular monitoring and control of the corrective action plan implementation. Communicate the risks associated with the control deficiencies identified along with regular investigative, analytic and audit reporting data to all stakeholders. This position has responsibility for the preparation and communication of status reports for Finance State of Compliance. Integrate processes designed to support the implementation of all Federal, State, and BSBSA mandates to include work necessitated by future changes in the dynamic regulatory environment. Incorporate complete transparency and accountability through the creation and maintenance of auditable supporting documentation such as Policies and Procedures, SOPs, workflows, and training materials.
Supports the Finance Compliance program by developing the control architecture to achieve and maintain compliance with new Federal, State, and BCBSA regulations.
• Assist the Manager in the development and implementation of Finance’s compliance program to ensure compliance and alignment with Federal, State, and BSBSA regulatory statutes and requirements.
• Ensure correct interpretation of the Federal, State, and BSBSA regulatory operational requirements in the changing regulatory environment, mitigating risk of exposure in the event of a conflict between the requirements
• Assists the Manager in developing and implementing a comprehensive risk based audit program to effectively test controls, continuously review, and improve departmental policies and procedures to achieve greater efficiencies and effectiveness.
• Provide support to the Manager Director in the interpretation of regulations and regulatory rules/guidelines to demonstrate the Finance Division is in compliance with state and federal standards.
• Maintains positive, responsive, respectful relationships with all internal and external customers.
• Maintain a central content repository by gathering and organizing compliance-related policies, applicable insurance laws and regulations and ensure a department policy and procedure exists for each law/regulation.
This position is responsible for supporting a culture consistent with CareFirst’s mission, values, ethics and Code of Conduct. Through their day to day actions, this position shall demonstrate and convey risk and compliance adherence principles and practices to encourage adoption and acceptance of those practices.
Under the direction of the Manager, Risk & Regulatory Compliance, principle duties and responsibilities include, but are not limited to, the following:
• Coordinate and schedule internal audits.
• Continuously analyze and align all functional area Policies and Procedures, SOPs, workflows, and systems and ensure they are in compliance and alignment with regulations.
• Review complex business processes, systems, workflows, SOPs, Policies and Procedures and policies to identify, document, and elevate the presence of risks and trends within, that may be non-compliant with contracts and or statutory requirements.
• Review internal controls, both manual and automated, and/or management controls in each functional area to remove any risk or exposure.
• Analyze controls for strengths and weaknesses ensuring special focus allocation to the specific risk areas creating the highest exposure to the Finance Division.
• Implement process and forum to review audit findings with stakeholders. Review audit findings with appropriate management staff to ensure accuracy. Perform follow-up activities related to audits/reviews and special projects and ensure corrective action and remediation occurs. Perform internal follow-up audits corrective actions have been implemented. Prepare audit report on follow-up audit activities.
• Work with management to establish and implement corrective action plan as an outcome of any audit findings.
• Assist management in discharging their responsibilities by mitigating risks, safeguarding assets, identifying fraudulent activities, complying with laws and regulations directly tied to operational efficiency.
• Monitor, assess, and report significant matters to the Risk & Regulatory Compliance Manager.
• Remain abreast of emerging issues and developments that have direct impact on the Business Unit.
• Apply continuous Quality Improvement principles to system, processes, departmental data and other relevant problems affecting audit and reporting requirements using analytical and problem resolution skills.
• Determines most appropriate solution and provides recommendations for solutions and/or corrective action.
Business Risk Management Program
• Support all aspects of the corporate insurance renewal including interacting with internal sources to collect renewal data and complete underwriting submissions for all lines of coverage. Analyze renewal data to ensure it meets requirements and is complete.
• Review insurance policies after issuance for accuracy of terms, conditions, rates, and premiums negotiated.
• Responds to internal and external requests and questions regarding insurance program, certificates, and coverage issues.
• Responsible for the coordination and reporting of property and casualty, and professional liability claims.
• Facilitate meetings between the carrier, internal and external counsel, and other internal parties to resolve claims as quickly as possible.
• Stays abreast of alternative risk control techniques in order to minimize risks for the Company and recommends appropriate alternatives.
• Collaborates with Facilities and Health & Safety to maintain a safe workplace for all associates. Serves as an educational resource to the Company’s employees and professional staff by conducting risk management training programs and/or designing broker/carrier-sponsored educational problems relating to risk management.
• Assists with routine updates to the detailed information supporting the Business Continuity/Emergency Response procedures (e.g. business impact analysis, identifying critical business functions, personnel assignments, hardware or software specifications, policies and procedures, etc.). Helps plan and coordinate simulation exercises involving critical business and support functions. Assists in documenting results of all tests and exercises.
A Bachelor’s degree in Finance, Accounting, Business Administration, Healthcare Compliance or related field is required. Minimum of 3+ years working experience in risk management, managed care and government programs, health insurance compliance programs, or related fields. Experience in project management, business process analysis, work flow, and task analysis; The ability to read and interpret insurance laws, regulations and policies is a must. Experience in state, federal regulatory oversight is required.
The Incumbent must display leadership qualities, functional expertise, and business perspective; Considerable judgment, tact, initiative, accuracy and trustworthiness; Excellent interpersonal skills with ability to build consensus and agreement and bring resolution to contentious issues and entrenched interests. This position also requires the ability to present and discuss regulatory compliance goals in a way that establishes rapport, persuades others, and gains commitment, the ability to research complex issues, interpret regulations and regulatory rules/guidance, and exhibit sound judgment in determining a recommendation or solution to a problem, demonstrated ability to lead problem-solving discussions, flexibility and the ability to adapt to shifting priorities, to work independently as well as part of a team .
The successful candidate will possess strong organizational, coordination skills and interpersonal skills for facilitating Compliance audits, the ability to gather and analyze data and generate reports, knowledge of local systems (such as Facets, Oracle, PeopleSoft, SunGard, etc.) and experience with hardware and software required in order to understand how they interface with the compliance regulatory statutes
Must be experienced and proficient with Word, Advanced Excel and database management and related software applications; Excellent oral and written communications; able to communicate and make presentation to all levels of management and associates at all levels throughout the Company; must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Travel may be necessary to coordinate audits throughout the Finance Division.
Knowledge of organization and operations of the business areas being supported An understanding of legal requirements and expectations for health insurance operations.
Department: Risk Management
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 04/07/2019
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The employee is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship