Manager, Regulatory Affairs - Medicare

Date: Oct 14, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5000 


Position Summary/Position


Under the direction of the Director of Compliance, 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) has an active and visible leadership role with CMS.
Under the direction of the Director, Compliance. the Manager, Regulatory Affairs (Medicare) serves as a lead liaison for IEHP with regulatory agencies, and positions IEHP as a key influencer, maintaining relationships with CMS. This position works collaboratively with other departments within the Plan acting as a resource to provide analysis and interpretation of regulatory policy guidance, and work with Business Units to ensure compliance with the regulatory requirements of the guidance issued. Additionally, the Manager, Regulatory Affairs (Medicare) plays a key role in crafting and shaping federal regulatory policy issues for the benefit of IEHP.
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. Identify, direct and maintain Regulatory Affairs (Medicare) Unit metrics for the purpose of driving process improvements and efficiencies.
6. Assume a leadership role within the organization and oversee the interpretation of complex federal and state regulatory guidance. Guide the Regulatory Affairs Unit Team Members to serve as a resource to ensure that Business Units are provided with regulatory support to ensure compliance. This includes overseeing the interpretation, distribution, and implementation of Health Plan Memo Systems (HPMS),  Dual Policy Letters (DPLs), etc.
7. Lead, guide, manage, and as appropriate attend in the participation of relevant committees and work groups, make presentations, prepare reports, data, or other materials. These may include, but are not limited to internal workgroups, workgroups convened by trade associations and workgroups convened by regulatory agencies.
8. Lead and oversee Regulatory Affairs Unit Team Member participation of various CMS regulatory agency calls and provide feedback to CMS Medicare Account Manager and other regulators from both Federal and State agencies as it relates to the Medicare line of business.  Communicates outcomes, as appropriate, to relevant Business Units.
9. Identify potential Medicare 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. Partners with Business Units and provide guidance on how to avoid or prevent similar risks in the future. 
10. Work closely with the Director of Compliance to support the CEO in fostering strong relationships with regulatory agencies. Oversee and manage the development of memos for the CEO and senior leadership to provide analysis on key emerging regulatory policy issues.
11. Serve as the primary liaison by establishing collaborative working relationships with CMS. Partners with Government Affairs, participating in selective collaborative relationships with the California Association of Health Plans (CAHP), Local Health Plans of California (LHPC), other trade associations, as well as Medi-Cal Managed Care Plans that are specific to Medicare Regulatory Affairs as needed.   
12. Provides subject matter expertise and collaborates with Governmental Affairs when requested for responses to trade association inquiries specific to Medicare line of business.
13. Oversee and facilitate resolution of high-visibility, escalated requests and issues from CMS, DMHC and DHCS, including but not limited to Member and Provider cases.

Supervisory Responsibilities

Leader: Administers Hires, Terminations, and Performance Reviews

Experience Qualifications


A minimum of five (5) years with managed care health plan or other relevant industry experience specific to CMS, DHCS/DMHC requirements. Direct experience interacting with regulatory agencies. Three (3) years supervisory experience.

Preferred Experience


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

Education Qualifications


Bachelor’s degree from an accredited institution required.

Preferred Education


Master’s degree from an accredited institution preferred.

Professional Certification


Certified in Healthcare Compliance (CHC) or commitment to obtain within one year of employment.  

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


Major Functions (Duties and Responsibilites) Continued:

14. 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.

15. Develop, review, and implement internal and external policies and procedures to ensure compliance with the Medicare contract, contract amendments, state and federal statutes and regulations, CMS published HPMS memos, Final Rules, DMHC Letters, DHCS Letters, policy transmittals, bulletins, and alerts.  Review departmental policies and procedures annually and recommend changes as needed.

16. Lead Medicare compliance initiatives and ensures continuous support for the operational areas during planning, development, and implementation of those initiatives. Assure implementation has been completed.
17. Communicate to all levels of the Plan to ensure support, awareness, and effectiveness of compliance with the Medicare and Medi-Cal contract, contract amendments, Federal and State statutes and regulations, CMS memos, call letters, final rules, bulletins and alerts.

18. 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.

19. 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.

20. 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.

21. Partners with operational areas to ensure operational policies and procedures  related to the Medicare line of business are compliant with Medicare regulatory and contractual requirements.  
22. Acts in a compliant manner. Supports the IEHP Compliance Program through own actions as well as aligning the expectations of direct reports and unit team members job expectations with compliant practices. Allows time for employees to complete compliance training, supports enforcement of policies and procedures, and proactively engages with team to encourage reporting of incidents of noncompliance.  Follows appropriate guidelines related to disciplinary action up to and including termination for violation of compliance expectations.



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  - $142,230.40  

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