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Regulatory Affairs & Compliance Analyst, Sr. (Medicare)

CalOptima – Orange, CA

This position ensures CalOptima and its subcontracted health networks and physician groups comply with federal and state standards, regulations, contractual provisions, and laws. Completes a variety of detailed analyses, including the impact of public policy changes from the State of California and the Federal government on CalOptima. The incumbent works with CalOptima management staff, health network/physician groups, members, management staff, and others as required. He/she will support projects and other assignments in the Regulatory Affairs & Compliance department.


Position Responsibilities:


  • Develops, implements and manages processes, policies and procedures and coordinates with appropriate departments to ensure CalOptima, as well as its subcontracted health networks, are in compliance with state and federal standards and requirements.
  • Reviews, analyzes and interprets regulatory requirements to determine impact and the appropriate health plan action. Communicates action(s) to the affected departments and facilitates the implementation of necessary action.
  • Reviews and make recommendations as applicable the marketing materials review process for regulatory approvals for all Medicare programs.
  • Identifies and completes investigations, including corrective action plans, on compliance issues.
  • Resolves all Medicare complaints and collaborates with team members to communicate the complaints resolution to the appropriate agency.
  • Conducts regular and ongoing compliance validation of relevant standards, guidelines, waivers, contractual provisions or other regulations to which CalOptima must comply.
  • Conducts ongoing exclusion monitoring of CalOptimas vendors.
  • Conducts readiness assessment for all Medicare programs based on regulatory requirements.
  • Supports the manager with interactions and responses to regulatory representatives, on compliance-related issues as needed.
  • Supports efforts related to regulatory audits, reporting requirement and filings for all CalOptima Medicare programs.
  • Leads presentations to a variety of audiences regarding Medicare regulatory requirements.
  • Other projects and duties as assigned.


Required Skills

  • Evaluate regulations to identify significant impact to CalOptima and recommend policies to comply and apply and ensure compliance to applicable regulations.
  • Instill effective cooperation and compliance. Develop rapport and facilitate cooperation, as well as recommend remedial or corrective actions when necessary.
  • Effectively communicate both verbally and in writing; excellent report writing, and presentation skills are essential.
  • Coordinate effectively with various departments, develop and prepare coordinated responses and ensure uniformity and continuity.
  • Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Services.


Required Experience

Experience & Education:


  • Bachelors degree in Public Administration, Health Care Administration, Business or other related field or an equivalent combination of education and experience is required.
  • Minimum 3 years of experience in a managed care organization, interacting with governmental requirements and regulations is required.
  • Minimum 2 years of experience with Medicare Advantage, Medicare Part D, Cal MediConnect, and PACE regulatory requirements and compliance is required.
  • Experience in contracting, monitoring, and enforcing contract provisions and quality management preferred.

Knowledge of:


  • Principles and practices of managed care.
  • Principles and practices of effective contracting and monitoring of the application of contracts.
  • Federal and state regulatory and other requirements and practices related to Medicare Advantage, Medicare Part D, Cal MediConnect, and PACE.
  • Effective methods and techniques for enforcement, compliance and effecting change.
  • Effective methods for coordinating the work of interactive groups.

Grade: L


#CB

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