DSNP Regulatory & Reporting Specialist

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age. Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths. Support all aspects of the Care Management (CM) compliance program for the Dual Special Needs Program (DSNP). Assume the primary role of interfacing with the Compliance department, Auditors, Vendors and Health Service (HS) staff for purposes of monitoring and ensuring compliant operations for the DNSP Program. Essential Responsibilities: In partnership with Compliance staff and Health Service leadership, develop auditing and monitoring plans to assess compliance with all State, Federal and internal business rules and regulations for the DNSP program. Serve as an inter-departmental liaison for compliance. Inform all regulatory requirement changes or updates that impact business operations and workflow decisions to ensure that programs are compliant with State, Federal an internal business rules and regulations. Maintain a current working knowledge of all applicable Medicare, and Medicaid rules and DNSP regulations including assessment, impact report and training on any new rules or regulations to all impacted departments and employees. Conduct frequent monitoring activities of all CM business operations, publish results and report out to CM Leadership, Compliance Department, quality committees and other PacificSource leadership teams as applicable on DNSP compliance. Respond to all DNSP compliance related inquiries from internal Compliance Department Staff and external auditors in a timely, professional, and accurate manner to ensure minimal organizational and operational impact. Be in state of readiness for an internal or external audit of DNSP program by having records, files, auditing materials organized and prepared as requested. Work collaboratively with CM leadership to produce and monitor department policies and procedures as applicable and ensure their regular maintenance to reflect new practices and guidance. Provide interpretation, as well as support training, and implementation of DNSP, Medicare, and Medicaid regulations and communicate them appropriately with respective departments and teams. Attend weekly meetings; review and approve external communications; and monitor operational performance reports. Support ongoing communication efforts. Maintaining compliant member, CM, and provider communications. Keeping letters and other member communications up to date with DNSP compliance guidance and best practices. Supporting Responsibilities: Meet department and company performance and attendance expectations. Gather and analyze data on program performance and be comfortable organizing data and results for multiple audiences. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of four years of CM related health insurance experience required. Strong preference for experience in auditing or compliance related role. Experience in using multiple data reporting and analytic platforms preferred. Strong knowledge base in understanding and applying Medicare and Medicare requirements preferred. Experience and training in Quality Improvement methodology preferred (PDSA, LEAN). Education, Certificates, Licenses: High school diploma or equivalent required. Bachelor’s or Associates degree preferred. Knowledge: Strong computer skills. Excellent verbal and business writing skills. Excellent public relations skills. Good understanding of Medical Terminology and Regulatory language required. Ability to comprehend and apply regulatory language and develop action plans to assure compliance. Requires ability to define and prioritize problems and manage workload without direct supervision. Competencies Adaptability Building Customer Loyalty Building Strategic Work Relationships Building Trust Continuous Improvement Conflict Management Contributing to Team Success Negotiation Skills Planning and Organizing Problem Solving Quality Improvement Work Standards Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 15% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility
, Group Problem Solving, Listening (active), Organizational skills/Planning and Organization, Teamwork Our Values We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business: We are committed to doing the right thing. We are one team working toward a common goal. We are each responsible for customer service. We practice open communication at all levels of the company to foster individual, team and company growth. We actively participate in efforts to improve our many communities-internally and externally. We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community. We encourage creativity, innovation, and the pursuit of excellence. Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively. Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times. PacificSource is anything but a typical health insurance company. Founded in 1933, we’re an independent, not-for-profit organization that puts our members, and their communities first—across Idaho, Oregon, Montana, and Washington. It's our 1,900 employees who make it happen: promoting health equity and partnering with providers to deliver better access to optimal, affordable care. So yes, with PacificSource, you get to do great things. In our effort to put members first—more than 600,000 of them—initiative, commitment, and hard work are supported and rewarded with excellent benefits, competitive wages, and opportunities for personal growth and advancement. Benefits: Flexible telecommute policy, medical, vision, and dental insurance, incentive program, paid time off and holidays, 401(k) plan, volunteer opportunities, tuition reimbursement and training, life insurance, and options such as a flexible spending account. We love our common purpose. Empowerment, flexibility, and sharing success make for a great place to work. Here’s what else we feel good about: A mission with a real sense of shared values Competitive wages and outstanding benefits, including telecommuting Opportunities for learning development and career advancement Organizational leadership style rooted in servant and transformational leadership A commitment to support the communities we serve A belief in the importance of work-life balance June 29: The Dalles, Pride Fair and Parade, 10a-5p (The Dalles, OR) PacificSource is an equal opportunity employer and a company that loves helping people. We work with our employees to understand their goals, and provide training, individual development, and career advancement opportunities to help them achieve just that. In 2023 alone we had 407 internal promotions! Top Workplace 2024 USA | USA Today Certified Age Friendly Employer, 2023 | Age Friendly Institute Top Workplace 2023 and 2022 for Idaho | Idaho Press Top Workplace 2023 and 2022 for Oregon and SW Washington | The Oregonian #4 Healthiest Employer of Oregon 2021 | Portland Business Journal Healthy Worksite 2021 | Design Coalition in Montana PacificSource is an equal opportunity employer. Click here to review our AAP Policy Statement. If you have questions about working at PacificSource or need help with your application, please email HRrecruiting@PacificSource.com.