Regulatory Affairs Director - Hybrid
CareSource, Dayton, OH, United States
ElderServe Health is a mission-driven, nonprofit managed care organization serving the New York metropolitan area. ElderServe provides long-term services and supports to more than 20,000 older adults and adults with disabilities across New York City, as well as Westchester, Nassau, and Suffolk Counties. ElderServe primarily serves a frail and elderly membership who is predominantly dual-eligible and enrolled in Medicaid managed long-term care, Medicare-only and integrated Medicaid-Medicare plans. The CareSource and ElderServe affiliation addresses these critical long-term care needs to help members be as healthy and independent as possible.
Job Summary The Regulatory Affairs Director is responsible for leading activities of the Regulatory Affairs Department, including contracts, compliance, surveys, audits, investigations, reporting, plan development and renewal, credentialing, Fraud, Waste & Abuse Special Investigations, provider network and relations, regulatory updates and compliance matters.
Essential Functions
Review, draft, negotiate and process agreements and amendments in accordance with organization guidelines.
Lead projects involving the collection and submission of data and information related to government audits, surveys and requests.
Oversee provider contracting, including letters of agreement and associated follow-up.
Review, disseminate and handle fair hearing (FH) notices and decisions; manage FH calendar; attend FHs as needed, review and handle communications with OTDA and submit reports; prepare status reports and updates on cases.
Lead activities of the Special Investigation Unit (SIU), including SIU reporting and internal investigations.
Review and update applicable HIPAA policies and procedures in compliance with HIPAA laws and regulations.
Review OIG/OMIG requirements and best practices for compliance and program integrity; review and updated compliance materials, including manuals, policies and procedures, and handbooks, to comply with regulatory requirements.
Make recommendations based on best practices and draft policies and procedures.
Review DOH and CMS plan contracts and edit plan documents in compliance with contract requirements.
Review, clarify and disseminate CMS memos and DOH guidance; keep abreast of related laws, regulations and official guidance.
Coordinate document and requests of outside counsel for litigation matters.
Oversee provider credentialing process and related activities.
Draft policies, procedures, manuals, plan and member materials.
Provide guidance and direction to Department staff.
Perform any other job related duties as requested.
Education and Experience
Juris Doctor (J.D) degree from an accredited college/university required
Five (5) years experience with Medicare and NY Medicaid managed care contracting and compliance required
Previous leadership experience preferred
Competencies, Knowledge and Skills
Strong customer service and team orientation
Ability to adapt to a changing environment to achieve results
Demonstrated leadership skills
Skilled in organization, workflow analyses and management of details
Advanced Microsoft Office skills, including Word
Strong editing and proofreading skillsExcellent written and oral communications skills
Excellent time/project management and prioritization skills
Ability to excel in fluid, dynamic environment
Licensure and Certification
Current, unrestricted Attorney license required
Working Conditions
General office environment; may be required to sit or stand for extended periods of time
Ability to travel as required by the needs of the department.
2 Days work from home; 3 Days work in Bronx office each week
Compensation Range $135,600.00 - $237,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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Job Summary The Regulatory Affairs Director is responsible for leading activities of the Regulatory Affairs Department, including contracts, compliance, surveys, audits, investigations, reporting, plan development and renewal, credentialing, Fraud, Waste & Abuse Special Investigations, provider network and relations, regulatory updates and compliance matters.
Essential Functions
Review, draft, negotiate and process agreements and amendments in accordance with organization guidelines.
Lead projects involving the collection and submission of data and information related to government audits, surveys and requests.
Oversee provider contracting, including letters of agreement and associated follow-up.
Review, disseminate and handle fair hearing (FH) notices and decisions; manage FH calendar; attend FHs as needed, review and handle communications with OTDA and submit reports; prepare status reports and updates on cases.
Lead activities of the Special Investigation Unit (SIU), including SIU reporting and internal investigations.
Review and update applicable HIPAA policies and procedures in compliance with HIPAA laws and regulations.
Review OIG/OMIG requirements and best practices for compliance and program integrity; review and updated compliance materials, including manuals, policies and procedures, and handbooks, to comply with regulatory requirements.
Make recommendations based on best practices and draft policies and procedures.
Review DOH and CMS plan contracts and edit plan documents in compliance with contract requirements.
Review, clarify and disseminate CMS memos and DOH guidance; keep abreast of related laws, regulations and official guidance.
Coordinate document and requests of outside counsel for litigation matters.
Oversee provider credentialing process and related activities.
Draft policies, procedures, manuals, plan and member materials.
Provide guidance and direction to Department staff.
Perform any other job related duties as requested.
Education and Experience
Juris Doctor (J.D) degree from an accredited college/university required
Five (5) years experience with Medicare and NY Medicaid managed care contracting and compliance required
Previous leadership experience preferred
Competencies, Knowledge and Skills
Strong customer service and team orientation
Ability to adapt to a changing environment to achieve results
Demonstrated leadership skills
Skilled in organization, workflow analyses and management of details
Advanced Microsoft Office skills, including Word
Strong editing and proofreading skillsExcellent written and oral communications skills
Excellent time/project management and prioritization skills
Ability to excel in fluid, dynamic environment
Licensure and Certification
Current, unrestricted Attorney license required
Working Conditions
General office environment; may be required to sit or stand for extended periods of time
Ability to travel as required by the needs of the department.
2 Days work from home; 3 Days work in Bronx office each week
Compensation Range $135,600.00 - $237,400.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
#J-18808-Ljbffr