Operations Regulatory Specialist II

Responsibilities

• Provide analytical support and leadership for key internal Operations projects
• Represent operations on cross-functional project work teams
• Submit, monitor and prioritize IT tickets for the Operations departments
• Review special projects and identify issue trends and potential resolutions
• Assist with reporting and processes that are regulatory related and tied to state issues deadlines
• Assist with the development, drafting and review of P&P’s and job aides for Operations
• Assist in educating/training Business Partners on operations functions
• Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data when requested by Compliance
• Perform analysis of all claims data to provide decision support to Claims management team in relation to regulatory requests
• Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues
• Partner and collaborate with Operations Business Owners to ensure all audit and regulatory deliverables are met accurately and on time
• Prepare Operations Business Owners for live questions and answers with the state regulators or auditors
• Track and assist with remediation efforts for Corrective Action Plans related to all audit findings
• Ensure the timeliness submission of the Regulatory Reporting required by the state and federal agencies for Operations
• Track all Compliance required training on a yearly and new hire basis for Operations
• Assist with all readiness activities in relation to implementation of a new line of business for Operations

• Bachelor’s degree or equivalent years of relevant work experience required
• Minimum of two (2) years of healthcare operations environment is required
• Regulatory and/or compliance experience is preferred
• Advanced level experience in Microsoft Word, Excel and Power Point
• Data analysis and trending skills
• Demonstrated understanding of claims operations specifically related to managed care
• Advanced knowledge of coding and billing processes, including CPT, ICD-9, ICD-10 and HCPCS coding
• Ability to work independently and within a team environment
• Attention to detail
• Familiarity of the healthcare field
• Critical listening and thinking skills
• Negotiation skills/experience
• Strong interpersonal skills
• Proper grammar usage
• Technical writing skills
• Time management skills
• Strong communication skills, both written and verbal
• Customer service orientation
• Decision making/problem solving skills