Resp & Qualifications
This position will work in collaboration with the Manager of Regulatory Compliance in coordinating SBU 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 the monthly status report for SBU State of Compliance. Integrate processes designed to support the implementation of all state and federal mandates to include work necessitated by future changes in the dynamic ACA 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 SBU Compliance program by developing the control architecture to achieve and maintain compliance with new Federal and State regulations.
• Assist the Manager in the development and implementation of the SBU’s compliance program to ensure compliance and alignment with Federal, State regulatory statutes.
• Ensure correct interpretation of the Federal and State regulatory operational requirements in the changing ACA environment, mitigating risk of exposure in the event of a conflict between the two.
• Assists the Manager and Director 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 and Senior Director in the interpretation of regulations and regulatory rules/guidelines to demonstrate CareFirst BCBS Strategic Business Unit and its delegated entities are in compliance with state and federal standards.
• 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.
PRINCIPAL ACCOUNTABILITIES: Under the direction of the Manager, Regulatory Compliance SBU, the 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 and remain updated and current in collaboration with the SBU’s Training and Quality areas.
• 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 especially in the claims processing, enrollment and service arenas – all jurisdictions, all products, all processing platforms to include our subsidiaries and vendors.
• 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 Business Unit.
• 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 on each functional group to ensure that the department has implemented corrective actions. Prepare audit report on follow-up audit activities.
• Work with SBU management to establish and implement corrective action plan as an outcome of any audit findings.
• Assist SBU 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 Compliance Manager and the Senior.
• 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.
• Update and maintain several departmental report for internal use and for distribution to senior management.
Minimum of 3+ years working experience in health insurance industry, managed care and government programs, health insurance compliance programs, or related fields. A Bachelor’s degree in Business Administration, Healthcare Compliance or related field is required. 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.
Travel is necessary to coordinate audit primarily in both the DC and MD offices and other sites as 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 and surround systems , 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.
Knowledge of organization and operations of the business areas being supported such as CareFirst Systems and experience in Claims, Enrollment and Billing and Service. An understanding of legal requirements and expectations for health insurance operations.
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: 5.1.21
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 associate 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 associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship