Enterprise Regulatory Compliance Audit & Monitoring Program Admin I

Summary

Job Description:

The Enterprise Regulatory Compliance Program Administrator evaluates new and evolving federal and state regulatory guidance and assesses their impact on enterprise-wide business processes, products, and operational strategies. This role partners closely with functional business areas to translate complex regulatory guidance into practical risk-based compliance solutions and supports the ongoing administration of an effective regulatory compliance program.

The Administrator plays a key role in monitoring regulatory change, performing impact assessments, supporting audits and examinations, and advising business partners to ensure compliance with applicable requirements issued by regulatory and oversight agencies, including but not limited to the Centers for Medicare & Medicaid Services (CMS), New York State Department of Health (DOH), Department of Financial Services (DFS), Department of Labor (DOL), Office of Inspector General (OIG), and Office of the Medicaid Inspector General (OMIG).

Essential Accountabilities

Level I

• Supports oversight and execution of regulatory compliance activities for assigned business areas, including implementation, monitoring, and documentation of regulatory requirements within the Enterprise compliance framework. This may include system research and analysis and data gathering and evaluation through interactions with internal business area staff throughout the organization.
• Responsible for interpreting federal and state regulatory guidance and responding to compliance-related inquiries, providing clear, practical guidance to business partners regarding company products, services, and operations.
• Monitors changes in regulations both at the state and federal level which may affect the operations of the Health Plan and its subsidiaries. Assesses for any impact to programs, operational procedures, policies, and systems supporting the organization’s Medicare, Medicaid, Commercial, and retail market programs.
• Collaborates with cross-functional teams including but not limited to Customer Service, Product and Operations, Marketing, Sales, Claims, Enrollment, Pharmacy, Quality Office, Utilization Management, and Advocacy to support regulatory compliance readiness and implementation, including gathering evidence of compliance.
• Participates in regulatory risk assessments by identifying potential compliance vulnerabilities, assisting with root cause analysis, and supporting development of corrective actions and remediation plans.
• Collaborates with assigned internal business areas to support adherence to regulatory compliance key performance indicators (KPIs) and related reporting and remediation when metrics are not met.
• Contributes to and supports the development of compliance communication tools, training and monitoring activities to promote awareness and understanding of regulatory requirements.
• Attends business and project meetings to proactively identify compliance considerations and mitigate regulatory risk.
• Participates in Compliance Oversight Committees (COCs).
• Assists in preparing accurate documentation, reports, and responses for regulatory filings, surveys, audits, and information requests.
• Supports Federal, State, and accreditation audits and examinations.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
  
  

Level II (in addition to Level I Accountabilities)

• Operates with increased autonomy and serves as subject matter expert and resource to operational areas regarding compliance, governance, and risk matters.
• Independently coordinates and facilitates cross-functional work groups, when necessary, to support implementation of new or revised regulatory requirements.
• Leads or co-leads regulatory change management initiatives, including communication planning, implementation tracking, and effectiveness monitoring.
• Represents the organization on external calls with vendors, business partners, industry groups, or the BlueCross BlueShield Association, as applicable.
• Support the coordination and oversight of audits or reviews conducted by third parties or external vendors.
• Shares regulatory knowledge and best practices with peers and business partners.
  
  

Level III (in addition to Level II Accountabilities)

• Manages highly complex, high-risk, or enterprise-wide regulatory compliance issues and provides expert guidance to senior leadership, stakeholders, and operational teams.
• Serves as a key point of contact with regulatory agencies and represents the organization during regulatory discussions, audits, or examinations.
• Represents leadership in Compliance committees, governance forums, and enterprise workgroups.
• May lead or oversee internal audits or external regulatory audits, examinations, or corrective action efforts, including regulator engagement and response strategy.
• Provides mentorship and guidance to less experienced team members and acts as a trusted advisor.
• Contributes to the ongoing maturity and effectiveness of the enterprise compliance program.
  
  

Minimum Qualifications

NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

Level I

• Seven or more years’ experience in health insurance or health care delivery, or bachelor’s degree in related area with four or more years of related experience.
• Working knowledge of federal and state health care regulatory frameworks affecting Medicare, Medicaid, and commercial products.
• Extensive knowledge of regulatory initiatives and legislation that impacts the health insurance industry. Understanding of regulations and ability to administer compliance for all areas across an organization.
• Familiarity with utilization management, authorization, and claims and enrollment processing workflows and systems.
• Strong project coordination skills with the ability to manage multiple priorities.
• Demonstrated ability to conduct regulatory research, analyze guidance, and translate requirements into business-ready recommendations.
• Strong research, analytical, and creative critical thinking skills. Capacity to identify and understand business objectives and associated risks of the operational area under review in order to make recommendations to improve the effectiveness or efficiency of regulatory operational processes.
• Excellent verbal and written communication skills and ability to communicate regulatory concepts clearly to diverse audiences.
• High degree of accountability, follow-through, and attention to detail.
• Proficiency with Microsoft Office and enterprise systems.
  
  

Level II (in Addition To Level I Qualifications)

• Nine or more years of relevant experience, or bachelor’s degree with six or more years of related experience.
• Advanced knowledge of health insurance regulations and compliance program operations.
• Demonstrated experience managing multiple complex regulatory initiatives or compliance projects.
• Ability to exercise sound judgement and operate independently with minimal supervision.
• Strong stakeholder engagement and influence skills.
  
  

Level III (in Addition To Level II Qualifications)

• Eleven or more years of relevant experience, or bachelor’s degree with eight or more years of related experience.
• Professional certification preferred (i.e., CPCO, CHC, CHPC, HCCA-related credentials).
• Proven expertise in resolving highly complex regulatory compliance issues and projects and management of regulatory audits.
• Ability to operate with the highest degree of initiative, leadership, and strategic thinking.
• Recognized as a trusted compliance advisor across the organization.
  
  

Physical Requirements

• Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer.
• Ability to travel within the service region for meetings, audits, or trainings as needed.
• Role requires extensive review, analysis, and interpretation of regulatory documentation.
  
  

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s)

Minimum: $65,346 - Maximum: $117,622

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.