Regulatory Compliance Analyst (Hybrid)
Job Description
Resp & Qualifications
PURPOSE:
The Regulatory Compliance Analyst will conduct independent analysis and determination regarding the eligibility and legal appropriateness of provider open negotiation requests and independent dispute resolution initiations (IDRs) for No Surprises Act (NSA) and state NSA cases.
ESSENTIAL FUNCTIONS:
- Review and analyze to determine eligibility and to develop substantive argument to support CareFirst CIDRE selections/eligibility and offers on IDRs.
- Oversees the end-to-end process of the billing vendors and dispute resolution claim submission and payment requests. This includes the maintenance of the NSA tracking database and claims resolution from start to finish. Monitors claims, identify trends, presents opportunity areas, and prioritizes initiatives for performance improvement. Tracks outcomes of payment resolution and negotiated claims to ensure goals are met.
- Provide interpretation of regulations and regulatory rules/guidelines, including NSA and state reimbursement laws, to ensure compliance with federal requirements with the NSA IDR process.
- Improves NSA knowledge and other appropriate regulatory investigation job knowledge by attending educational workshops; reviewing professional publications; establishing personal
networks; benchmarking state-of-the-art practices; participating in professional societies. - Contributes to NSA IDR and company success by welcoming related, different, and new requests; helping others accomplish job results.
QUALIFICATIONS:
Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 1 year experience in a regulatory, compliance or customer service role.
Preferred Qualifications:
- Demonstrated experience with Excel, Salesforce, and claims processing systems.
Knowledge, Skills and Abilities (KSAs)
- Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
- Ability to convey information in a clear, concise, and logical manner.
- Ability to effectively convey information to others.
- Excellent critical thinking and communication skills both written and verbal.
- Consistently maintains highly professional written and verbal interaction with all levels of staff within the company and with members of regulatory agencies.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $54,864 - $108,966
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
#LI-LJ1
Resp & Qualifications
PURPOSE:
The Regulatory Compliance Analyst will conduct independent analysis and determination regarding the eligibility and legal appropriateness of provider open negotiation requests and independent dispute resolution initiations (IDRs) for No Surprises Act (NSA) and state NSA cases.
ESSENTIAL FUNCTIONS:
- Review and analyze to determine eligibility and to develop substantive argument to support CareFirst CIDRE selections/eligibility and offers on IDRs.
- Oversees the end-to-end process of the billing vendors and dispute resolution claim submission and payment requests. This includes the maintenance of the NSA tracking database and claims resolution from start to finish. Monitors claims, identify trends, presents opportunity areas, and prioritizes initiatives for performance improvement. Tracks outcomes of payment resolution and negotiated claims to ensure goals are met.
- Provide interpretation of regulations and regulatory rules/guidelines, including NSA and state reimbursement laws, to ensure compliance with federal requirements with the NSA IDR process.
- Improves NSA knowledge and other appropriate regulatory investigation job knowledge by attending educational workshops; reviewing professional publications; establishing personal
networks; benchmarking state-of-the-art practices; participating in professional societies. - Contributes to NSA IDR and company success by welcoming related, different, and new requests; helping others accomplish job results.
QUALIFICATIONS:
Education Level: Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 1 year experience in a regulatory, compliance or customer service role.
Preferred Qualifications:
- Demonstrated experience with Excel, Salesforce, and claims processing systems.
Knowledge, Skills and Abilities (KSAs)
- Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
- Ability to convey information in a clear, concise, and logical manner.
- Ability to effectively convey information to others.
- Excellent critical thinking and communication skills both written and verbal.
- Consistently maintains highly professional written and verbal interaction with all levels of staff within the company and with members of regulatory agencies.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $54,864 - $108,966
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
#LI-LJ1
About CareFirst BlueCross BlueShield
Named by the Ethisphere Institute as one of the “World’s Most Ethical Companies” for 10 consecutive years.
CareFirst. It’s not just our name. It’s our promise. Over 3.5 million people trust us with their healthcare needs, and we take this responsibility seriously.
Our vision for healthcare is clear. Quality care should be easy to afford, easy to use and available to everyone. And what we’re building for you is exactly what we expect for ourselves and those we love.
Every day, we make a meaningful difference in the communities where we live and work. We solve real problems for the people we serve with equal parts empathy and urgency—simplifying the complex, delivering tailored solutions and stepping forward with new ideas.
RECRUITMENT FRAUD NOTICE: CareFirst is aware of an increase in fraudulent job offers being made on behalf of our recruitment team. Legitimate CareFirst recruiters will always contact you from an email address ending in “@carefirst.com” and will never ask for a payment in exchange for a job opportunity or ask you to submit sensitive personal information via email, phone, or text.
COVID-19 VACCINATION NOTICE: As a leading healthcare organization, it is our responsibility to do our part to help end this pandemic and protect the health and well-being of our members, workforce, communities, businesses and partners. Our recruiters continue to fill open positions. Interviews and other processes are being modified to protect the safety of our candidates and team members. Effective November 1, 2021, COVID-19 full vaccination is required for all employees, including those who work remotely today or in the future. CareFirst will comply with all state and local laws regarding vaccine mandates. Medical and religious exemptions will be made where appropriate using our standard vaccine exemption processes.
Independent licensee of BCBSA.
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