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Director of Regulatory Affairs - Remote

Job ID: 2205020838 Date posted: 05/26/2022 Facility: Conifer Health Solutions
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Job Details

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

The Director of Regulatory Affairs will support Value Based Care Operations by providing regulatory support and assistance to health plans who delegate services to our clients.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

  • Direct clients with the development of regulatory filings and responses, specifically with regard to filings to due to California Department of Managed Care (DMHC).
  • Develop and maintain effective relationships with client partners and regulatory agencies including the DMHC.
  • Proactively monitor regulatory guidance and trends with respect to California healthcare and communicate changes to operational leaders and health plan clients.
  • Communicate and drive regulatory change processes needed to ensure effective organizational processes and policies.
  • Partner with operational and compliance department leaders as needed to ensure communication and management of regulatory requirements which may impact the organization and/or clients.
  • Provide compliance oversight and direction related to ACO and managed care initiatives.
  • Lead client specific Compliance Committee meetings consistent with client charter and department standard and operating procedure requirements.
  • Prepare and deliver ACO and managed care training and education in response to areas of responsibility needs/requests, investigations of compliance matters, and identified risk areas.
  • Oversee the implementation of corrective actions and monitoring in response to identified issues and audits.
  • Coordinate with client’s counsel to facilitate communication regarding health plan and regulatory requirements.
  • Act as a consultative resource on regulatory requirements.


Qualifications:

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment activity. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Experience in health plan management focusing on Medicare/Medicaid, Medicare Advantage Organizations and Commercial lines of business.
  • Experience reviewing, interpreting and applying applicable state, Federal and health care regulatory requirements.
  • State, Federal and CMS regulatory requirement knowledge including experience with CA DMHC and DHS regulatory requirements and processes related to Limited Knox-Keene plans and risk-bearing organizations. In addition to state, federal, CMS regulatory requirement knowledge, experience with CA DMHC and DHS regulatory requirements and processes related to Limited Knox-Keene plans and risk-bearing organizations would be helpful including DMHC reporting and filing requirements and understanding of All Plan Letter (APL) applicability.
  • Health plan operational process knowledge including network management, provider contracting, appeals, grievances and provider dispute resolution, quality/utilization management, credentialing, claims payment, coding and billing, and customer service. This is helpful in assisting with and responding to operations audits and other issues as well as assisting in ensuring DMHC response submissions are correct and accurate
  • Experience in application of Medicare Advantage first-tier, downstream and related entity (FDR) requirements and with oversight if downstream entities including MSOs and FDRs
  • Operational knowledge of office and facility clinical practices and regulatory requirements.
  • Ability to effectively respond to audit requests and develop professional working relationships with clients, regulators and other internal and external business partners.
  • Experience with Management Services Organizations, IPAs, and delegated operations activities including network management, provider contracting, appeals, grievances and provider dispute resolution, quality/utilization management, credentialing, claims payment, coding and billing, and customer service.
  • Experience in health plan administration focusing on Medicare/Medicaid, Medicare Advantage, and Commercial lines of business.
  • Excellent organizational, attention to detail, strong communication skills, analytical, critical thinking skills and the ability to respond under pressure.
  • An energetic and results-oriented leader who inspires confidence and possesses high personal and professional integrity.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

  • Bachelor’s Degree, Master’s Degree is preferred and 3-5 years of progressive experiencein the health care industry with extensive experience with ACO and managed care (orequivalent experience.)
  • Minimum five years’ experience in health care with specific experience working with the CA Dept of Managed Care.
  • Minimum three years’ experience with multiple lines of health plans including Medicare, Medicare Advantage, commercial, etc., and various organizational entities including MSOs, IPAs, etc.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Must be able to work in sitting position, use computer and answer telephone
  • Ability to travel
  • Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments

WORK ENVIRONMENT

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Must be able to work in sitting position, use computer and answer telephone

TRAVEL

  • Approximately 5% travel may be required
Job: Conifer Health Solutions
Primary Location: Frisco, Texas
Job Type: Full-time
Shift Type: Days

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet participates in the E-Verify program. Follow the link below for additional information.

E-Verify: http://www.uscis.gov/e-verify

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