Operations Regulatory Specialist II (Hybrid) Health Plan Experience & Facets Preferred

Operations Regulatory Specialist II

The Operations Regulatory Specialist II provides analytical support and leadership for key internal Operations projects and partners with the Operations departments to ensure all regulatory and compliance deliverables are met. This position works in the Dayton HQ office every Tuesday & Thursday.

Essential Functions :

• Represent operations on cross-functional project work teams
• Submit, monitor and prioritize IT tickets for the operations departments
• Review special projects and identify issue trends and potential resolutions
• Assist with reporting and processes that are regulatory related and tied to state issues deadlines
• Assist with the development, drafting and review of P&P's and job aides for Operations
• Assist in educating / training Business Partners on operations functions.
• Research and resolve provider claim issues and escalations by analyzing system configuration, payment policy, and claims data when requested by Compliance
• Perform analysis of all claims data to provide decision support to Claims management team in relation to regulatory requests
• Identify and quantify data issues within Claims and assist in the development of plans to resolve data issues
• Partner and collaborate with Operations Business Owners to ensure all audit and regulatory deliverables are met accurately and on time. These deliverables may include :
• Documentation gathering i.e. review of Standard Operating Procedure and / or Policy and Procedure to the audit / inquiry requirements
• Audit Universe monitoring and / or creation collaboration with IT and the Business Owners to validate the accuracy of the data and formatting of the final report for submission
• Prepare Operations Business Owners for live questions and answers with the state regulators or auditors
• Track and assist with remediation efforts for Corrective Action Plans related to all audit findings
• Ensure the timeliness submission of the Regulatory Reporting required by the state and federal agencies for Operations
• Track all Compliance required training on a yearly and new hire basis for Operations
• Assist with all readiness activities in relation to implementation of a new line of business for Operations
• Perform any other job-related instructions, as requested

Education and Experience :

Competencies, Knowledge and Skills :

Licensure and Certification :

Working Conditions :

Compensation Range : $61,500.00 - $98,400.00

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.

Compensation Type (hourly / salary) : Salary

Organization Level Competencies :

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.