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Manager, Regulatory Affairs - Medicare

Date: Mar 29, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 4387 


Position Summary/Position


Under the direction of the Director of Compliance and Regulatory Affairs/Compliance Officer, the Regulatory Affairs Manager (Medicare) is responsible to achieve and oversee compliance with Centers for Medicare & Medicaid Services (CMS) Medicare guidelines, regulations, and contractual requirements and to assist with implementation of these requirements into internal operational processes. 
The Regulatory Affairs Manager (Medicare) must promote open and candid discussions regarding Medicare compliance concerns, provide effective compliance oversight for Medicare obligations within the operational areas, and collaborate with key stakeholders.
Works very closely with the Manager, Regulatory Affairs (Medi-Cal), as well as other Managers within the Department to ensure alignment of priorities and division of responsibilities.

Major Functions (Duties and Responsibilities)


1. Direct the day-to-day operations of the Regulatory Affairs (Medicare) Unit in the most effective manner to meet Plan, department, and unit objectives while ensuring quality and accuracy of the work. Implement standardized processes to maximize efficiency.
2. Oversee employment of Team Members, including recruitment, performance reviews, training, coaching, and development.
3. Direct, train, and educate Regulatory Affairs (Medicare) Unit Team Members to ensure the Medicare line of business is in compliance with the regulatory and contractual requirements.
4. Develop and implement the annual regulatory reporting calendar. Define metrics to measure the success of the regulatory reporting calendar. If the metrics identify an area of concern, escalate the issue and take corrective action, as needed.
5. Direct and maintain Regulatory Affairs (Medicare) Unit Lean huddle board and metrics for the purpose of driving process improvements and efficiencies.
6. Serve as liaison to the CMS Medicare Account Manager and other regulators from both Federal and State agencies as well as trade associations and workgroups, as needed. Respond to inquiries from external agencies as it relates to the Medicare line of business.
7. Oversee and facilitate resolution of high-visibility, escalated requests and issues from CMS and DHCS, including but not limited to Member and Provider cases.
8. Lead Medicare compliance initiatives and provide continuous support for the operational areas during planning, development, and implementation of those initiatives. Assure implementation has been completed.
9. Identify potential risks, non-compliance and/or alleged violations within the Plan, and work with Compliance Audit & Oversight Unit to develop and implement department and unit corrective action plans (CAPs) for resolution. Provide guidance on how to avoid or prevent similar risks in the future. 
10. Understand reported issues, document, and communicate them appropriately and identify mechanisms to prevent these issues from occurring in the future. Escalates, as warranted, instances of potential non-compliance to the Compliance Officer. 
11. Determine the appropriate objectives, scope and methodology to ensure Plan compliance with the Medicare contract, and contract amendments. Review and understand Federal and State regulations, including but not limited to, CMS-published HPMS memos, Call Letters, Final Rules, and Office of the Insurance Commissioner requirements as well as other publications applicable to the various business lines for which IEHP may be rendering services.
12. Cultivate an effective system for ensuring that relevant legislative, regulatory, enforcement and administrative developments and trends are reviewed promptly, analyzed carefully, and communicated to the relevant business leads in a constructive manner.
13. Organize and lead external audits from Federal regulatory agencies. Assure Team Members are prepared for the audit and any requested documents are delivered promptly. Act as the contact person during the audit.
14. Lead, facilitate, or participate in relevant committees and work groups; make presentations; prepare reports, data or other materials for committee presentation.
15. Create policy and procedures for the Regulatory Affairs (Medicare) Unit and assist the operational areas with their Medicare operational policies and procedures to ensure compliance with Medicare regulations. Review internal and external policies and procedures annually and recommend changes, as needed.

Supervisory Responsibilities

Leader: Administers Hires, Terminations, and Performance Reviews

Experience Qualifications


A minimum of 5 years with managed care or other relevant industry experience; and 3 years in a leadership position.

Preferred Experience


Experience in health care, health plans, Medicaid Managed Care Plans (MCPs), Medicare Advantage, Medicare Part D, Special Needs Plans (SNPs), and/or Medicare-Medicaid Plans (MMPs)/Cal MediConnect (CMC).  Experience interacting with regulatory agencies.

Education Qualifications


Bachelor’s degree from an accredited institution required.

Preferred Education


Master’s degree from an accredited institution preferred.

Professional Certification


Pursuing, or attained, applicable compliance designation (e.g., Certified in Healthcare Compliance)

Professional Licenses

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


Knowledge of principles and practices of managed care operations. Knowledge of Federal and State regulatory requirements related to Medi-Cal (Medicaid), Title 19 (USC)/Title 29 (USC and CFR), Title 22 (CCR), Title 28 (CCR), Title 42 (USC and CFR), CA WIC, and CA Health and Safety Code. Principles of project management. Principles of project management.

Skills Requirement


Strong leadership and interpersonal skills. Excellent verbal and written communication skills. High level of analytical ability. Strong organizational skills. Microsoft Office programs including, but not limited to: Word; Excel; Power Point; Outlook.

Abilities Requirement


Ability to understand, incorporate and demonstrate the mission, vision, and values of the Plan in behaviors, practices, and decisions. Ability to maintain a high level of diplomacy Ability to analyze complex regulatory requirements. Ability to be resourceful and independent in problem solving and self-direction. Ability to establish and maintain effective working relationships with internal departments and external agencies. Ability to embrace and champion change to accommodate evolving organizational and regulatory processes. Ability to work independently and collaboratively within a team environment. Ability to manage multiple projects with competing deadlines and changing priorities. Strong attention to detail.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


Occasional travel within the continental United States. 

Physical Requirements

Keyboarding: Traditional - FREQUENTLY
Keyboarding: Touch-Screen - FREQUENTLY
Keyboarding: 10-Key - FREQUENTLY
Hearing: One-on-One - FREQUENTLY
Communicate: Information/ideas verbally - FREQUENTLY
Near Visual Acuity - FREQUENTLY
Regular contacts: co-workers, supervisor - FREQUENTLY
Understand and follow direction - FREQUENTLY
Regular and reliable attendance - CONSTANTLY


Starting Salary: $111,550.40

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles