The Regulatory Affairs & Compliance Analyst (Medicare) coordinates and maintains CalOptima’s relationships with regulatory agencies, which includes, but not limited to, supporting, enhancing and strengthening CalOptima’s policy infrastructure/platform/strategy at the state and federal level, including contract compliance, statutory and regulatory obligations with the Department of Health Care Services (DHCS) and the Centers for Medicare & Medicaid Services (CMS); as well as, coordinating and assessing the policies and programmatic implications of compliance activities for CalOptima. This position also requires a variety of detailed analyses, including the impact of public policy changes from the State of California and the Federal government on CalOptima. Interacts and functions as a liaison with CalOptima’s internal departments and external regulatory agencies/organizations.  

POSITION RESPONSIBILITIES:

• Monitors regulatory communications from the DHCS and CMS and manages daily relationship in support of CalOptima’s Medicare programs.
• Researches, keeps current on local, state, and federal healthcare regulations, updates policies, procedures, determines impact, recommends and facilitates the implementation of necessary action to major initiatives for CalOptima’s Medicare programs (e.g., integration of new benefits and populations) as well as to other affected departments
• Builds and maintains open lines of communication with regulators and management for ongoing trust and confidence of the program.
• Works with CalOptima departments in response to inquiries, problem-solving, promoting our mission and the development of marketing materials for the Medicare programs including the annual member materials (i.e., Evidence of Coverage, Summary of Benefits, Provider Directories).
• Coordinates, tracks, and files regular and ad-hoc reports to DHCS and CMS.
• Participates and represents CalOptima in meetings and calls with regulators and associations and summarizes key points and impact to CalOptima’s Medicare programs.
• Supports the activities of the Compliance Committee and assists in the implementation of the Compliance work plan. 
• Identifies and completes investigations of all Medicare complaints and works with Regulatory Affairs & Compliance leadership to communicate, to the appropriate agency, the complaint’s resolution and corrective action plans.
• Conducts regular and ongoing compliance validation of all relevant standards, guidelines, waivers, contractual provisions or other regulations to which CalOptima must comply.
• Supports efforts related to regulatory audits, including support to Manager with interactions and responses to regulatory representatives, for all CalOptima Medicare programs, and follow up with issuance of corrective action plans (CAPs) to remediate the non-compliance issues identified in the regulatory audits.
• Develops compliance tracking tools, as needed.
• Other projects and duties as assigned.

Required Skills

• Work independently.
• Have strong organization skills and work on numerous projects concurrently.
• Communicate effectively, both verbally and in writing, with all levels of staff, and external stakeholders.
• Possess initiative and follow-through on projects with minimal supervision or guidance.

Required Experience

EXPERIENCE & EDUCATION:

• Bachelor’s degree in related field and/or equivalent work experience is required. Master’s degree preferred.
• 2+ years of experience in health care compliance, in either a provider or managed care setting preferred.
• Experience working with regulatory agencies in California preferred.
• Experience in healthcare or health plan requirements preferred.

KNOWLEDGE OF:

• Principles and practices of managed care.
• Principles and practices of effective contracting and monitoring of the application of contracts.
• Federal and state regulatory and other requirements and practices related to Medicare Advantage, Medicare Part D, Cal MediConnect, and PACE.
• Effective methods and techniques for persuasion and enforcement, compliance and effecting change.
• Effective methods for coordinating the work of interactive groups.
• Microsoft Office suite, including Outlook, Word, Excel, and PowerPoint. Proficiency in Visio and Microsoft Project a plus.

Grade:  K

#CB

• Work independently.
• Have strong organization skills and work on numerous projects concurrently.
• Communicate effectively, both verbally and in writing, with all levels of staff, and external stakeholders.
• Possess initiative and follow-through on projects with minimal supervision or guidance.