Excellus BlueCross BlueShield Regulatory Compliance Analyst in Rochester, Syracuse or Utica, New York
The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.
Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.
OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.
With minimal direct management oversight, this position researches, analyzes and processes all corporate regulatory complaints for all lines of business and analyzes survey responses from vendors. This includes in-depth research, analysis, decision making and written notice to the regulator. This position is also responsible for Corporate Compliance escalations related to regulatory complaints through vendor survey analysis identifying instances of no non-compliance. Executes and manages escalated compliance matters through implementation. Assesses compliance vulnerabilities, conducts root cause analysis, and recommends, initiates and oversees process improvement activities. Identifies compliance best practice opportunities, recommends process refinements, brings practical improvements to implementation and produces policy recommendations.
• Independently handles cases involving mainly regulatory groups such as but not limited to Office of the Attorney General, NYS Department of Financial Services, NYS Department of Health,
• Assesses the business impact for state and federal regulations and mandates.
• Processes escalations discovered through regulatory complaints through the Corporate Compliance Closed Loop process for remediation.
• Researches, interprets and communicates regulation requirements to internal customers. Provides and supports training or reference materials as appropriate.
• Renders decisions, within reasonable latitude, given the circumstances of the case or the survey, and follows regulated requirements for case reviews.
• Provides written and/or oral responses to all complaints in appropriate business formats ensuring that the decision is communicated clearly to the customer as these decisions are binding for the corporation.
• Documents cases in a timely and professional manner ensuring that cases are easily understood.
• Ensures all department and regulated timeframes are met.
• Develops and executes compliance communication tools and training and monitoring programs to ensure continued compliance.
• Assesses potential non-compliance vulnerabilities, identifies root causes of issues and provides practical business recommendations for corrections.
• Reviews and analyzes escalated regulatory issues against current policies and practices and works with business area representatives to reach meaningful and appropriate resolution and implementation.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
• Bachelor’s degree in relevant field desired. A minimum of seven years of related experience in customer operations, medical management or compliance. Experience must include at least three in Advocacy role.
• Must be familiar with government regulations including but not limited to CMS, Managed Care law, UR law, DOL/ ERISA legislation and Health Care Reform and must stay continually informed.
• Must have complete knowledge of all claims processing systems, contracts, and riders.
• Requires excellent oral and written communication skills.
• A thorough knowledge of current policies, procedures, and rules for all lines of business, plus federal and state activities as they relate to subscriber’s rights.
• Must be able to effectively communicate with all levels of employees in the corporation as well as external customers.
• Must have the ability to mentor Advocacy staff.
• Knowledge of corporate operations, corporate goals and objectives and the organization’s structure.
• Extensive knowledge of regulatory initiatives and legislation that impacts the Corporation.