It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Regulatory Operations Manager is responsible for supporting the Service & Operations division with compliance with regulatory requirements by reviewing and implementing federal and state guidance, and by leading audit preparations and responses. This position additionally is responsible for maintaining accurate documentation, developing internal controls, supporting business areas in applying regulations, and overseeing audit activities across various programs and agencies.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

* Review and implementation of HPMS memos, CMS proposed/final rules impacting operations, changes to Part C managed care benefit manuals

* Review/implementation of DHHS regulatory guidance memos impacting operations

* Review/action of state Medicaid contract amendments

* Leads preparation of appropriate documentation for state, federal, internal, external and mock audits

* Responsible for leading the Plan responses during audits and for follow up for action plans

* Responsible for the accuracy of all required documents and the updating of those documents as required by contractual, regulatory and accreditation requirements

* Works with business leaders to validate attestations for product applications

* Oversees the development and maintenance of internal controls and quality assurance to monitor against all applicable standards

* Supports business areas to identify, interpret and apply regulation requirements. Works with managers to develop and implement required workflows

* Ensures letters, policies and procedures are current and have gone through the required internal and external approval processes

* Works with training and documentation partners as needed to develop training, materials and job aids of staff for regulatory and compliance issues

* In collaboration with the appropriate managers, develops and supports the necessary corrective action plans when opportunities for improvement are identified based on QA or audit functions

* Participates in appropriate committees that support program compliance

* Acts as liaison to Compliance, Legal and Public Partnerships Departments

* Creates centralized repositories for regulatory materials and RFP responses

* Audit activity includes but is not limited to:

* NH EQRO audit - annually

* NH PMV audit - annually

* Ad hoc NH audits such as quality, encounter data, network all of which have an Ops impact

* MA SCO EQRO audit - 1 every 3 years

* MA ACO/MCO EQRO audit - 1 every 3 years

* CMS data validation audit - annually

* Ad hoc CMS audit activity such as program audits, financial activity reviews, risk adjustment reviews

* Ad hoc state Medicaid audits or validation reviews that might pop up

* CMS call center audits - validation reviews

Supervision Exercised:

* This is an individual contributor role

Supervision Received:

* General guidance is received weekly

* This role will report into and support the Service & Operations division though will work closely with the corporate compliance department

* This role will also work closely with the Service & Operations division regulatory reporting analyst, public affairs department and business leaders

* This role may also interact with internal or external auditors or state and federal agencies

Qualifications:

Education Required:

* Bachelor's Degree or an equivalent combination of education, training and experience is required

Education Preferred:

* Master's degree in a related field preferred

Experience Required:

* 5+ years of managed care experience in compliance or government programs

* 5+ years of experience with Medicare or Medicaid programs

* 5+ years of experience with regulatory contracts and requirements

Experience Preferred/Desirable:

* Health plan operations experience

Required Licensure, Certification or Conditions of Employment:

* Successful completion of pre-employment background check

* Employees must provide high speed internet meeting minimum required standards

* Employees are required to have a quiet and distraction-free working space and protect confidential information

Competencies, Skills, and Attributes:

* Excellent organization and proven process improvement skills

* Ability to discern regulatory details and requirements from contracts

* Strong oral and written communication skills; ability to interact within all levels of the organization

* A strong working knowledge of Microsoft Office products

* Demonstrated ability to successfully plan, organize and manage projects

* Detail oriented, excellent proof reading and editing skills

* Demonstrated ability in facilitating cross-functional teams and encouraging positive collaboration and communication

* Demonstrated ability to work independently and manage multiple projects simultaneously

* Demonstrated commitment to excellent customer service for both internal and external customers

* Understands and is able to work in highly matrixed environments

* Effective collaborative and proven process improvement skills

* Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts

* Strong analytical and problem solving skills

Working Conditions and Physical Effort:

* Ability to work in a fast paced environment

* Regular and reliable attendance is an essential function of the position

* Work is normally performed in remote office work environment; limited travel may be required

* Ability to work East Coast business hours

* No or very limited physical effort required

* No or very limited exposure to physical risk

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees