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Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware Job Summary: This position is responsible for working independently to ensure documented operational compliance to state, federal, and accreditation standards in Utilization Management and/or Case Management as related to mental health parity. Is the Regulatory Mental Health Parity clinical department subject matter expert in UM regulatory compliance requirements of MHPAEA, DOBI, IPRO, State, CMS and NCQA. Makes recommendations on process improvements/changes required to comply with regulatory standards. The individual creates and maintains library of policies, workflows, and audit documentation related to Mental Health Parity and CMS clinical requirements. Track and trend operational deficiencies identified by internal and external regulatory/accreditation audit and identify and implement opportunities for improvement. Responsible for training and education as applicable to staff related to regulatory standard updates.
In addition, the position collaborates with clinical areas and legal/ Compliance/reregulate to understand business implications and impacts to workflows, policies, and operations as a result of regulatory changes or laws. The individual prepares business correspondence, audit action plans, and reports, as well as maintain and improve the multiple policies and procedures that must operate in parity to ensure compliance with relevant regulatory compliance requirements. The incumbent is responsible for preparing and presenting policies and procedures that impact compliance with mental health Parity, NQTLs, and its corresponding factors to clinical committees. This individual is responsible for assuring that all clinical staff are trained and apply all Mental Health Parity and CMS regulatory clinical standards appropriately to assure clinical staff compliance in both the Physical and Behavioral Health Clinical Departments.
Responsibilities:
- Act as the Clinical Subject Matter Expert (SME) with in collaboration with Legal, Regulatory, Compliance, Quality and other departments as applicable on contract changes and regulatory audit compliance applicable to UM and CM as related to Mental Health Parity.
- Lead cross-functional work streams and compliance pertaining to mental health parity and the regulation of mental health and substance use disorder benefits.
- Lead the development of policies and analyses supporting the Company's ongoing compliance with state and federal parity requirements. This will include cross-functional collaboration with actuarial on quantitative treatment limitation analysis, as well as collaboration with HNS and other managed care functions and non-quantitative treatment limitations.
- Responsible for modifying and enhancing educational and training UM and CM materials related to the regulation of mental health and substance use disorder benefits, and other key policy developments impacting the operation of individual, group, and governmental health plans.-Lead for staff education and training related to MHPAEA /NCQA/DOBI/IPRO/CMS standards and related audit findings.
- Analyzes complex data and information to provide meaningful results, identifying success factors and improvement opportunities, recommending potential solutions to assist the business set strategic goals.
- Review non-standard benefits for compliance with applicable regulatory compliance laws
- Subject matter expert (SME) for MHPAEA, State, DOBI, IPRO, CMS, NCQA and internal audit preparation and review on the company benefit products (Medicaid, Medicare, Commercial) to assure consistency and compliance of subscriber/member contracts, provider agreements, and other regulated contracts, with respect to benefit and network administration, and other Company operations. Work closely with Contract Administration and Product Administration to assure that new benefit products or strategies align with regulatory compliance requirements.
- Prepare comparative analysis of written operational policies and on-going qualitative and quantitative analysis to monitor the NQTL factors compliance. Track and Trend data on audit deficiencies and identify and implement opportunities for improvement.
- Assist the clinical areas with regulatory audit preparation, provide guidance on findings, and prepare plan response to audit findings.
- Responsible for implementation of department Corrective Action Plans associated with external audit findings.
- Identify opportunities to align policies across all lines of business and between Physical Health and Behavioral Health UM and CM teams.
- Educate on policy and contract changes and ensure applicable operational procedures/ job aids are updated for compliance.
The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.
Education/Experience:
- Bachelor's or Master's preferred, in a healthcare degree from an accredited college or university.
- Requires a minimum of 5 years of business experience, preferably in the health insurance industry in a clinical role or as a health policy advisor.
- Requires minimum of 2 years of providing regulatory guidance (analyzing and interpreting laws and regulations) or compliance experience, preferably in health insurance focus on Mental Health Parity and NQTL audit responses.
- Experience with health insurance contract preparation and/or employee benefits plan drafting is preferred.
Additional licensing, certifications, registrations:
- Clinical licensure preferred (RN, LPC, LCSW)
Knowledge:
- Requires general business knowledge of the health insurance industry
- Regulatory Compliance at the State and Federal level
- Mental Health Parity knowledge/background required
- Requires knowledge of Utilization management in Managed Care
- Prefer working knowledge of health benefits plans, state and federal laws and regulations as they apply to group contracts, federally funded governmental healthcare programs, insurers and familiarity with state departments of Insurance and/or Health
Skills and Abilities:
- Requires advanced analytical skills and the ability to present/recommend business solutions
- Requires excellent organizational and prioritization skills
- Requires the ability to work and communicate effectively with all levels of business, including senior and executive leadership
- Requires excellent oral and written communication/presentation skills
- Effective analytical & problem solving skills to propose creative solutions to regulatory needs
- Collaborative and client service focused to effectively deliver actionable requirements and solutions
- Must demonstrate professional and ethical business practices and adherence to company standards
- Must demonstrate the ability to effectively present information and respond to questions from groups of managers, internal and external clients, and company customers
- Must demonstrate the ability to learn quickly and apply learning to new situations. Must exhibit flexibility to adapt to new regulatory requirements and compliance regimes as appropriate
- Demonstrated proficiency in Microsoft Office Suite
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law." Salary Range: $76,800 - $102,795
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
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Horizon Blue Cross Blue Shield of New Jersey
tuition reimbursement
Dec 20, 2024