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Organization TypePublic Interest
Years of Experience
Date Last Verified
Regulatory Consultant IV Responsibilities: Responsible for leading California state regulatory initiatives across all functions statewide, as well as managing relationships and maintaining communications with stakeholders at all levels, both internally and externally. Researches, plans, implements, and monitors a broad portfolio of regulatory systems and initiatives to enable organizational compliance with all applicable Federal, state, and local regulations/laws. Advises the organization on all regulatory matters related to the Department of Managed Health Care (DMHC) and other state regulators. On an on-going basis, researches and interprets regulations and laws to establish standards, and may develop and/or deliver training and communications/change management relative to new standards. Assesses organizational systems (both physical and process or data related) to determine gaps in compliance and determine opportunities for remediation. Advises the organization on all compliance matters. May investigate violations of compliance policy, laws, regulations, etc. or conduct on-going monitoring and reporting to ensure remediation. May be responsible for project management relative to new compliance initiatives, products, or annual processes. Assessment of organizational systems and processes to ensure appropriate Health Plan oversight and survey readiness and determine gaps for remediation prior to regulatory surveys. All regulatory filings related to Health Planâ€™s Knox-Keene license (ex. contracts, benefits, delivery systems, new products).Benefits interpretation to ensure statewide consistency in providing benefits to members and compliance with benefits provisions in contracts. Processing regulatory complaints in a timely manner and trending, reporting, and analyzing data related to these complaints.. May be responsible for project management relative to new regulations, legislation, surveys, new products, or other issues involving state regulators.. Developing and directing proactive regulatory strategies to support membership growth.. HPREO is responsible for:. Evaluating, interpreting, identifying and documenting business impacts and overseeing the implementation of the work as a result of Federal Commercial and Medicaid rules, regulations and laws across all functions and regions. Managing relationships and maintaining communications with stakeholders at all levels and management and/or oversight of ongoing operations required for participation on public exchanges. Analysis of Federal commercial and Medicaid rules, regulations, laws and guidance to understand the business impacts. Ensure ownership for implementation. Serve as the FFM Exchange lead by overseeing end to end administrative operations and responding to questions and issues from the regulator. Monitor all product and rate filings. Lead the QHP recertification Community of Practice and oversee successful QHP recertification in all jurisdictions. Responsible for project oversight relative to implementation of new Federal Commercial and Medicaid regulations, rules or laws. Manages, creates, and maintains client relationships. An understanding of end to end business operations and business functions and how regulations impact business operations. May be responsible for management of complex business processes required for participation on public exchanges and communicate with stakeholders. Fosters comprehensive regulatory management through a series of activities to comply with all applicable regulations and statutes. Activities include: Planning: identifying and may lead the identification of regulatory accountabilities; identifying and may lead the identification of internal and external resources; developing and/or overseeing the development of regulatory work plans; participating on and may establish regulatory-related work groups; and managing external agency relations, Implementing: identifying regulatory requirements and conducting related analyses; creating or revising regulatory standards, policies, and procedures; monitoring regulatory adherence; and reporting on regulatory efforts and programs, and Validating: reviewing regulatory programs and content. Researches and stays abreast of regulations and statutes. Determines impacts of implementation of new regulations and statutes and required notifications, changes, and training. Communicates required changes, and leverages existing workgroups/etc. to facilitate required changes. Lead the development of operational policies and procedures that are complex involving multiple regions and departments. Provides on-going coaching, enabling team members to develop and improve skills and capabilities that support the effectiveness of the department and/or function. Serves as a technical/professional mentor to team members. Provides performance input and recommendations to management for development/training plans and/or performance reviews. May have formal supervisory responsibilities. Manage moderately sized project teams.
Qualification and Experience
Qualifications: Bachelorâ€™s degree OR 4 years of experience in a directly related field. High School Diploma or GED required. 9+ years of health care experience or other applicable experience-health care operations, audit, finance, project management, regulatory or public policy development, investigations, information security, or insurance/health plan governance experience. Advanced knowledge of health care operations, regulatory policies, practices and systems and regional operational differences. Contributes to the development of regulatory concepts. Broad knowledge of health care industry practices and standards. Ability to draft and revise documents including analyses, and reports. Project management and/or consulting skills. Years spent in law school resulting in a law degree may count as applicable job experience.
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