Healthnow NY, Inc.
Regulatory Specialist, Provider Network Regulatory Compliance (Finance)
This position is accountable for activities related to validating the accuracy of the Health Plan's Provider Network demographic data through the performance of audit related activities ; preparation of evidence related to Health Plan compliance for regulatory surveys and audits; research and timely and accurate processing of Office of Professional Medical Misconduct (OPMC) Final Action notifications; Assist in the development, review, and revision departmental standard operating policies and procedures; assist with and support team with the review and formatting of provider/facility credentialing and recredentialing files in preparation for surveys, and serve as a member of the Corporate Credentials Committee as assigned.
Auto req ID
2701BR
Knowledge and Skills
In depth working knowledge of Provider Enrollment/Provider Network policies and procedures and their relevancy toward regulatory guidelines of NYSDOH, CMS, and NCQA. Strong administrative, organizational and time management skills Excellent verbal and written communication skills Ability to prioritize assignments, deadlines and demands, including on time regulatory agency responses Responsive to internal and external customer inquiries Familiarity with NYS Education department policies, procedures and regulations. Knowledge of OPMC provider disciplinary action process Must be self-motivated to work independently and effectively Ability for engagement and collaboration with team members, internal and external customer inquiries High level of business maturity, professionalism, and demonstrated confidentiality Proficient with Microsoft Office
Qualifications
Problem Solving Skills: 1.Identifies issues and problems- Recognizes issues; identifies key facts; trends, and issues; separating relevant from irrelevant data.
2.Seeks information - Identifies/recognizes information gaps or the need for additional information; obtains information by clearly describing what needs to be known and the means to obtain it; questioning clearly and specifically to verify facts and obtain the necessary information.
External Contacts: Providers, NYS OPMC
About Us
At BlueCross BlueShield of Western New York, we believe in passion, excellence, and respect. Employees enjoy guaranteed career development opportunities, robust health care coverage, and work-life programs to help them thrive in every stage of their lives. We give back to Western New York through programs and volunteer work that have the greatest impact on the health of the community we serve. As the region's strongest community-based, not-for-profit health plan, BlueCross BlueShield of Western New York aims to inspire and help our members achieve their best health and wellness. Join us in building a healthier future in the place we call home.
Company
BlueCross BlueShield of WNY
Status
Full Time Regular
Experience
Minimum of three (3) years of experience with a health care insurance plan. Experience with regulatory/compliance matters preferred.
Health care credentialing preferred. Bachelor's degree in business or a health care related degree/field preferred. Equivalent combination of education and experience will be considered.
EEO Statement
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.
Hours
8 - 5 Monday - Friday
Working Conditions
Must be able to work in an office environment Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc) Mental effort: Adequate to perform essential functions of the job with the type of judgements and responsibilities as indicated in the job description.
Education
Required Education:Associates Degree (N/A)