The Compliance Specialist is responsible for working with the Compliance Manager and/or Senior Compliance Specialist & Medicare Compliance Officer to ensure Dean Health Plan's compliance with state and federal regulatory requirements (e.g. Wisconsin insurance law, federal health care reform, federal ERISA, HIPAA privacy and security, and Medicare managed care). Duties may include, subject to the direction and concurrence of the Compliance Manager: interpreting regulations and identifying compliance requirements, assessing likely risks and recommending compliant solutions that support business goals; supporting workforce education about compliance requirements; assisting with benefit interpretation; and drafting policy language to reflect compliance and business-driven changes.
Essential Job Duties:
Support a comprehensive compliance program by drafting policy language, procedures and supporting other activities to increase the organization's effectiveness in meeting the compliance program standards.
Serve as an expert on compliance matters that affect Dean's products by identifying compliance requirements and recommending compliant solutions that support business goals.
Assist in the preparation and review of Annual Compliance training materials, company intranet articles and/or other training and education materials presented by Compliance.
Research and provide comprehensive, helpful answers to the business via the Regulatory Compliance Request (RCR) process. Prioritize, store and prepare reports on the RCR process as requested.
Partner with other areas of Dean as appropriate to establish and maintain a high level of compliance.
Assist Compliance Solutions Analysts in synthesizing regulatory changes impacting Dean's products to ensure a complete and accurate understanding of the change and associated business implications.
Investigate compliance issues, detect possible violations, and assist Compliance Solutions Analysts in implementing corrective action.
Prepare and present management summaries on regulatory compliance topics.
Provide regulatory compliance expertise to the Internal Audit team during regulatory audits or in preparation for discretionary audit activities.
Under the direction of the Compliance Manager, submit regulatory filings related to existing and new products (including but not limited to commercial policy forms; Medicare marketing materials and marketing events, Medicare Cost reports; and contracts with CMS).
Other Job Duties
Serve as Dean's liaison with various external lobbying groups.
Assist the HIPAA Privacy Officer in the execution of those duties, including fostering awareness of the importance of safeguarding Protected Health Information (PHI).
Perform other duties as assigned.
A bachelor's degree and 3-5 years relevant work experience, preferably with managed care and/or government programs compliance issues.
Familiarity with Wisconsin's managed care environment, Dean Health Plan products, the Affordable Care Act and/or the HIPAA Privacy Rule.
Strong analytical and problem solving skills.
Able to independently research, understand and apply regulatory requirements in a corporate setting.
Able to draft insurance policy/benefit language, corporate policies and procedures and proposed legislation.
Detail-oriented, organized, and able to manage multiple priorities to effectively meet production and regulatory deadlines in a fast-paced work environment.
Works well both independently and in a high-producing team environment.
Works with other departments to foster collaborative relationships that promote corporate compliance.
Able to write clearly for the general workforce, corporate decision makers and regulators.
Strong verbal communication skills.
Strong PC skills in Windows environment (including Word and Excel).
Valid driver's license and personal, reliable vehicle is required for work related travel in order to fulfill position responsibilities.
At least two years of experience with Medicare managed care compliance (Cost or Medicare Advantage), including management of regulatory deadlines, application of Medicare Marketing Guidelines, use of HPMS, interpretation of CMS memos, and interaction with CMS personnel.
At least two years of direct experience with the legislative or administrative process in the State of Wisconsin.
You’ve known us as many names throughout St. Louis, and now, we’re bringing our hospitals, doctors, home care and other services together under one name – SSM Health. With seven hospitals, 350+ physicians, more than 40 physician locations and 12,000 employees, we are part of something bigger and better. We’re connected to a wealth of resources, expertise and advance technology to help you, your fa...mily and our community live long, healthy lives.
We’ve grown and changed a lot over our 143-year history. Our name may be changing but our mission remains the same