Erm Specialist

The primary purpose of the ERM Specialist is to track, monitor, oversee and ensure all required regulatory standards are addressed and implemented into plan documents and required State and Federal filings. Duties include coordination of the plan document process, overseeing plan document due dates and performing quality reviews of the generation of plan document benefit charts, revisions and amendments based on regulation and business need to ensure accuracy and compliance.

Plan document oversight and completion may apply to Individual Health Plans, Standard Insured Group Health Plans, Multi-Employer Welfare Arrangements, and/or Self-Funded Health Plans. Additional duties may also include reviewing, entering, and tracking Health Insurance Portability and Accountability Act (HIPAA) and Power of Attorney (POA) requests related to personal representative designation and private health information (PHI) requests. The ERM Specialist is required to promote the timeliness and effectuation of HIPAA authorization review decisions that meet the standards set by CMS.

Department Summary

The Legal/ERM Team in the Legal/Enterprise Risk Management (ERM) Department completes commercially required regulatory filings, population and management of Individual and Group health plan documents, performs contract reviews, HIPAA and Privacy requests, as well providing support and guidance to the organization to promote and support risk management efforts.

Qualifications

• High School diploma or equivalent.
  • Some college preferred and/or equivalent experience in managed care or health care field.

Department Qualifications

Skills

• Computer experience in a windows operating system, experience with Microsoft Word, Outlook and Excel applications.

Department Skills

• Provides support to the ERM Coordinator.
• Completes regulatory filings.
• Annual review of plan document language for compliance with current law and ongoing due to legislative and regulatory changes. Facilitate language revisions, including legal approval.
• Ensure filing compliance per internal and external communication prior to filing with the State.
• Responsible for multiple State form filings: AC/AAG insured group, HMO group and ancillary filings through SERFF.
• Annual state rate filings, certifications, attestations, applications through SERFF and other mechanisms.
• Filing review and retention
  - Documentation of filing details, dates, approval numbers, etc.
• Ensure all approved insured documents are uploaded and are accessible via  and Ault Share.
• Monthly distribution of Teamsters plan documents and Enrollee Requests through the website.
• Annual quality review, population and distribution of Benefit Recipient Plan Documents.
• Communicate directly with our State and Federal Regulators as necessary.
• Understand and monitor changes to regulations under federal law, (i.e. ERISA and healthcare reform) and promote consistent application to plan documents based on revisions to regulations.
• Knowledge of mandatory disclosures in relation to document creation (i.e. Summary Plan Descriptions, Summary of Material Modifications).
• Incorporate required notice requirements (i.e. denial notices, applicable Part 7 ERISA notices, etc.).
• Quality Review of development of Self-Funded SPD amendments and new plan documents.
• Tracking of Self-Funded SPDs and Amendments.
• Update the manual and policies to keep working instructions current.
• Coordinate the distribution of SPDs at the request of the company.
• Upload plan documents to Ault Share for internal use and oversee Plan Doc Requests  Inbox.
• Acts as a main contact with operational areas in regard to any HIPAA authorization reviews and PHI requests.
• Conducts and tracks initial and monthly Ohio Inspector General/General Service Administration (OIG/GSA) checks for Vendors, Temporary Employees, Contractors, and Employees.
• Enters and tracks HIPAA Authorizations and POA requests.
• Maintains data tracking files and reports monthly volume of PHI requests processed to the Privacy Officer.
• Understands statutory and plan language restrictions, timelines, etc. that affect processing of HIPAA / PHI requests and contract execution.
• Process Improvement:
  Continuously reviews, recommends and implements improvement steps, as needed or directed.
• Other duties as assigned.
• Seeks supervisory guidance/approval as appropriate.
• Portrays professional image: follows dress code, communicates with internal and external customers in a professional manner, including appropriate verbal and written grammar.
• Promotes and demonstrates…