Regulatory Consultant IV - Evidence of Coverage Writer
Company: Kaiser Permanente
Location: Oakland
Posted on: June 20, 2022
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Job Description:
Highly preferred to have a Juris Doctorate (JD) The team within
Health Plan Regulatory Services (HPRS) that is looking to fill this
role is the California Contract and EOC Consulting (CCEC) team.
CCEC is primarily responsible for developing and maintaining
language for our commercial group and individual plan contracts and
evidences of coverage (EOCs). CCEC must develop contract language
that is legally enforceable, but still accessible to the average
reader. CCEC also prepares filings to the Department of Managed
Health Care, provides assistance to stakeholders regarding EOC
interpretation, and consults on a variety of regulatory issues.
HPRS is responsible for leading California state regulatory
initiatives across all functions statewide, as well as managing
relationships and maintaining communications with stakeholders at
all levels, both internally and externally. Researches, plans,
implements, and monitors a broad portfolio of regulatory systems
and initiatives to enable organizational compliance with all
applicable Federal, state, and local regulations/laws. Advises the
organization on all regulatory matters related to the Department of
Managed Health Care (DMHC) and other state regulators. On an
on-going basis, researches and interprets regulations and laws to
establish standards, and may develop and/or deliver training and
communications/change management relative to new standards.
Assesses organizational systems (both physical and process or data
related) to determine gaps in compliance and determine
opportunities for remediation. Advises the organization on all
compliance matters. May investigate violations of compliance
policy, laws, regulations, etc. or conduct on-going monitoring and
reporting to ensure remediation. May be responsible for project
management relative to new compliance initiatives, products, or
annual processes.HPRS is responsible for:+ Assessment of
organizational systems and processes to ensure appropriate Health
Plan oversight and survey readiness and determine gaps for
remediation prior to regulatory surveys. + All regulatory filings
related to Health Plan's Knox-Keene license (ex. contracts,
benefits, delivery systems, new products).+ Benefits interpretation
to ensure statewide consistency in providing benefits to members
and compliance with benefits provisions in contracts.Essential
Responsibilities:HPRS is reponsible for Continued:+ Processing
regulatory complaints in a timely manner and trending, reporting,
and analyzing data related to these complaints.+ May be responsible
for project management relative to new regulations, legislation,
surveys, new products, or other issues involving state regulators.+
Developing and directing proactive regulatory strategies to support
membership growth.HPREO is responsible for:Evaluating,
interpreting, identifying and documenting business impacts and
overseeing the implementation of the work as a result of Federal
Commercial and Medicaid rules, regulations and laws across all
functions and regions. This includes managing relationships and
maintaining communications with stakeholders at all levels and
management and/or oversight of ongoing operations required for
participation on public exchanges.HPREO is responsible for:+
Analysis of Federal commercial and Medicaid rules, regulations,
laws and guidance to understand the business impacts.+ Ensure
ownership for implementation.+ Serve as the FFM Exchange lead by
overseeing end to end administrative operations and responding to
questions and issues from the regulator.+ Monitor all product and
rate filings.+ Lead the QHP recertification Community of Practice
and oversee successful QHP recertification in all jurisdictions.+
Responsible for project oversight relative to implementation of new
Federal Commercial and Medicaid regulations, rules or laws.+
Manages, creates, and maintains client relationships. An
understanding of end to end business operations and business
functions and how regulations impact business operations.+ May be
responsible for management of complex business processes required
for participation on public exchanges and communicate with
stakeholders.+ Fosters comprehensive regulatory management through
a series of activities to comply with all applicable regulations
and statutes. Activities include:+ Planning: identifying and may
lead the identification of regulatory accountabilities; identifying
and may lead the identification of internal and external resources;
developing and/or overseeing the development of regulatory work
plans; participating on and may establish regulatory-related work
groups; and managing external agency relations,+ Implementing:
identifying regulatory requirements and conducting related
analyses; creating or revising regulatory standards, policies, and
procedures; monitoring regulatory adherence; and reporting on
regulatory efforts and programs, and+ Validating: reviewing
regulatory programs and content.+ Researches and stays abreast of
regulations and statutes. Determines impacts of implementation of
new regulations and statutes and required notifications, changes,
and training. Communicates required changes, and leverages existing
workgroups/etc. to facilitate required changes.+ Lead the
development of operational policies and procedures that are complex
involving multiple regions and departments.+ Provides on-going
coaching, enabling team members to develop and improve skills and
capabilities that support the effectiveness of the department
and/or function. + Serves as a technical/professional mentor to
team members.+ Provides performance input and recommendations to
management for development/training plans and/or performance
reviews.+ May have formal supervisory responsibilities.+ Manage
moderately sized project teams.Basic Qualifications:Experience+
Minimum nine (9) years of health care experience or other
applicable experience-health care operations, audit, finance,
project management, regulatory or public policy development,
investigations, information security, or insurance/health plan
governance experience.+ Years spent in law school that resulted in
a law degree may count as applicable job experience; JD will be
counted in lieu of 3 years of experience.Education+ Bachelor's
degree OR four (4) years of experience in a directly related
field.+ High School Diploma or General Education Development (GED)
required.License, Certification, Registration+ N/AAdditional
Requirements:+ Years spent in law school resulting in a law degree
may count as applicable job experience.+ Advanced knowledge of
health care operations, regulatory policies, practices and systems
and regional operational differences.+ Contributes to the
development of regulatory concepts.+ Broad knowledge of health care
industry practices and standards.+ Ability to draft and revise
documents including analyses, and reports.+ Project management
and/or consulting skills.Preferred Qualifications:+ JD+ Technical
contract writing/language technical abilities. + Health care
regulation experience+ Strong experience and an intereste in health
care are transferrable skills. Notes:+ Position may be hired in
NCal or SCal.COMPANY: KAISERTITLE: Regulatory Consultant IV -
Evidence of Coverage WriterLOCATION: Oakland, CaliforniaREQNUMBER:
1066362External hires must pass a background check/drug screen.
Qualified applicants with arrest and/or conviction records will be
considered for employment in a manner consistent with Federal,
state and local laws, including but not limited to the San
Francisco Fair Chance Ordinance. All qualified applicants will
receive consideration for employment without regard to race, color,
religion, sex, national origin, sexual orientation, gender
identity, protected veteran, or disability status.
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