Description

Resp & Qualifications

PURPOSE:
This Senior Regulatory Compliance Analyst position will conduct independent data mining, analysis and reporting. Participate in the design, development, validation and delivery of data to provide insight into business decisions. Collect, analyze, and interpret data to glean insights, and suggest business appropriate recommendations for complicated, high level regulatory inquiries and assist to demonstrate compliance with state and federal requirements related to Mental Health Parity. The incumbent will find meaning in data so that the derived knowledge can be used to make informed decisions and assist the organization in making better business decisions. Audit internal controls to identify high risk exposure, analyze data for trends and conduct comparative analysis Manage projects to develop solutions and strategies to remediate issues. Write business and technical requirements and document procedures to support efficiency, accuracy and duplicability.

ESSENTIAL FUNCTIONS:

• Relationship Management: (Internal/External)
• Liaison with IT and Data Analytics teams and participate in educational trainings to maintain skills in data management, mining and reporting. Liaison with Regulatory Agency Investigators (Maryland Insurance Administration {MIA}, Virginia Bureau of Insurance {VBOI} and the District Insurance, Security and Banking {DISB}, organization as well as state and federal level bureaucrats. Frequent interaction with all internal areas especially all Business Units, Legal, Compliance and Legislative Departments. Provide interpretation of regulations and regulatory rules/guidelines to demonstrate CareFirst BCBS and its subsidiaries' compliance with state and federal standards. Review and analyze all data received in order to generate detailed responses to the originating party. Strategizes with Legal and Compliance as needed to identify the best response to the complaint. Consistently maintains highly professional written and verbal interaction with all levels of staff within the company and with all members within regulatory departments. Maintain positive, responsive, respectful relationships with all regulators, internal business owners and external stakeholders. Serves as the subject matter expert for business processes and related systems as the representative of the company. Provide education regarding systems and process to internal and external stakeholders as needed and requested.

• Business Support
• Provide data analysis, research, resolve and respond to written inquiries forwarded from Congressional, Attorney General and State officials, members, providers, groups and brokers. Coordinate with internal and external parties to ensure accurate information is obtained. Review and analyze provided data and information. Provide detailed professionally written responses to originating party, ensuring all questions are answered and customer needs are effectively served within designated timeframes while ensuring privacy needs of members are respected. Review, analyze, prepare detailed documentation for support of legal action pertaining to CareFirst indemnity business, ensuring that all appropriate materials, related claims, contracts, payment vouchers are included. Develop a summary/assessment of included documentation for legal staff. Meet, discuss, and strategize with legal staff to prepare for depositions, court cases or administrative hearings. Appear as required to testify on behalf of CareFirst.

• System Compliance Analysis
• Review moderately complex business processes and systems to identify, document, elevate the presence of risks and trends within systems and processes that may be non-compliant with contracts and or statutory requirements especially in the claims processing, preauthorization, appeals, credentialing, enrollment and service arenas all jurisdictions, all products, all processing platforms to include our subsidiaries. Actively participate in implementation/corrective workgroups to ensure compliance perspective and concerns are addressed through the process.

• Litigation and Legal Support
• Review, analyze, prepare detailed documentation for support of legal action pertaining to CareFirst indemnity business, ensuring that all appropriate materials, related claims, contracts, payment vouchers are included. Develop a summary/assessment of included documentation for legal staff. Meet, discuss, and strategize with legal staff to prepare for depositions, court cases or administrative hearings. Appear as required to testify on behalf of CareFirst

• Special Projects
• Provide research, investigative and analytic support on special projects ensuring that all CareFirst policies and contractual guidelines are clearly identified. Provide support to supervisors and other internal associates with written responses to inquiries.

SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.

QUALIFICATIONS:

Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience: 5 years experience in a compliance or senior level customer service role.

Knowledge, Skills and Abilities (KSAs)

• Skill in using programming languages and providing technical support, and resource for data and systems questions.
• Skills in logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
• Ability to convey information in a clear, concise, and logical manner.
• Ability to effectively convey information to others.
• Excellent critical thinking and communication skills both written and verbal.
• Consistently maintains highly professional written and verbal interaction with all levels of staff within the company and with members of regulatory agencies.
• Able to provide interpretation of trends in data, and build a presentation that incorporates quantitative information, charts, graphs, etc.
• Must be able to interpret insurance law and regulations.

Preferred Qualifications:

• Data Science, Mathematics, Computer Science, Statistics, Business or related field
• Hands on experience with Big Data/NoSQL Platforms with experience delivering production projects at scale
• Experience with Managed Healthcare Organization Industry Databases
• Knowledge of Mental Health Parity: Non-Quantitative Treatment Limitations and Quantitative Treatment Limitations

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Mental Health Parity Compliance

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.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

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.

PHYSICAL DEMANDS:

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.

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