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SalaryOver 35 years strong and fueled by 1,700 smart, passionate employees across New York State and Vermont, MVP is full of opportunities to grow. We are a nationally recognized, award-winning leader for a reason. The beating heart of our company is a wide range of employees from a diverse set of backgrounds—tech people, numbers people, even people people—working together to make health insurance better. If you are ready to join a thriving, mission-driven company where you can create your own opportunities and make a positive difference—it’s time to make a healthy career move to MVP!
Full-Time, Exempt
Position is virtual/remote
position will be responsible for the coordination of all State and Regulatory audits and requests within the Operations Department. The Professional will ensure compliance with the issuance of all post service claims communications for Insured and ASO lines of business to promote the optimal member experience while continuing to adhere to State and Federal guidelines. They will be engaged with Corporate Compliance to ensure all regulatory requirements impacting Claims at the State and Federal level are communicated, implemented, and monitored to ensure compliance. They will also be responsible for delegated vendor oversight for state regulatory compliance working with both internal and external functional areas.
ESSENTIAL JOB FUNCTIONS:
1. Responsible to ensure the compliance of all State and Federal regulated post service claim denial letters, explanation of benefits, and all lines of business provider remittances. Ensures quality, cohesiveness with cross functional applications utilized with the issuing of these documents while adhering to all states and client expectations while identifying and promoting efficiencies in the issuance of these documents.
2. On behalf of MVP State regulated and ASO business entities, ensure delegated claims vendors are meeting all compliance regulations and service level agreements for Claims Operations through monthly monitoring, quarterly summary reports to upper-level management, and performance of an annual vendor audit. Responsible for developing executive audit reports for communication to Operations management and Delegated Oversite Committee. For any vendor not meeting the expectations set forth by MVP, Program Manager will develop a corrective action plan with such vendor and communicate progress with MVP management and DOC.
3. Plan, lead and coordinate for the Operations department all State and Regulatory Audits. This includes but not limited to; Department of Financial Services (DFS), Health Effectiveness Data Information Set (HEDIS), Department of Health (DOH) and Department of Labor (DOL). This position will be the primary liaison with agency auditors for the Operations Department and will be responsible in providing status updates to Management in an organized manner.
4. Primary liaison for Claims Operations for all legal inquiries and coordinate the responses to requests from the following: MVP Legal department, Business Compliance Management Team (BCMT), Attorney General, Department of Labor, Department of Financial Services, Department of Health. Adhere and ensure timelines for responses are met.
5. Will be responsible for operationalizing any new regulations and updates as assigned by BCMT, completing all requested documentation through this process, communicating to impacted areas the change in the regulation(s) and ensure we have appropriate processes and policies and procedures in place to ensure compliance.
6. Performs monthly review of Commercial and ASO EOB’s and Adverse Determination Letter’s to ensure our adherence with issuing appropriate member cost share and content.
7. Provides support in the quality review of monthly Medicare Part C Explanation of Benefits (EOB).
8. Provides back-up and support for all Commercial and ASO regulatory Remittance content and 835 testing that includes CARC/RARC mapping.
9. Will provide support for Prompt Pay reporting, interest as needed.
OTHER DUTIES & RESPONSIBILITIES:
1. Maintain professional standards of communication, both verbally and written to internal and external customers.
2. Proactive in identifying areas for opportunities of improvement and efficiencies in regulatory processes.
3. Ability to act in a consultative manner for Claims Operations for State and Federal Regulatory inquiries with all levels of the organization.
4. Ability to maintain confidentiality and adhere to regulatory compliance issues as they exist and change from time to time.
5. Performs other related duties as assigned.
POSITION QUALIFICATIONS
Education/Degree:
Minimum 4-year college degree preferred.
Minimum Experience:
Minimum 5 years health insurance experience, regulatory compliance preferred. Operations experience preferred.
Claims Processing experience preferred.
Required Skills:
- Strong organizational and management skills including ability to handle multiple tasks and take direction from several internal customers
- Ability to adjust priorities to meet multiple competing deadlines
- Vendor Management and Oversight preferred
- Influential verbal communication skills with both external and internal customers
- Superior written and oral communication skills sufficient to interact effectively and productively with staff, external customers, consultants and vendors.
- Ability to be flexible and adjust appropriately to frequent changes.
- Strong proficiency in problem solving and analysis
- Physical demands/Working conditions:
- Ability to support working occasional extended hours or weekend as needed to support timelines.
MVP Health Care is a nationally recognized, not-for-profit health insurer caring for members in New York and Vermont. Committed to the complete well-being of our members and the communities we serve, MVP makes health insurance more convenient, more supportive, and more personal. We are powered by the ideas and energy of more than 1,700 diverse employees from all backgrounds, committed to having a positive impact on the health and wellness of everyone we serve.
At MVP, we are committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. Specific employment offers and associated compensation will be made individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role.
In addition, we offer a comprehensive benefits package that includes:
- Considerable paid time away from work including PTO (Paid Time Off), sick time, service time off, paid holidays, and floating holidays, allowing you to take time off when it suits you best.
- Competitive 401(k) employer matching and profit-sharing program to help you save for your retirement.
- Low premium health benefits including medical, dental, and vision coverage to support your well-being and that of your family.
- Life insurance and disability coverage to ensure financial security for you and your dependents.
- An array of optional benefit plans such as accident insurance and specified disease coverage to protect you from the unexpected.
- Full tuition reimbursement (up to the IRS limit) for approved courses and programs that support continuous learning.
- A best-in-class employee Well-Being program to support all dimensions of your health and wellness.
MVP Health Care is an Affirmative Action/ Equal Employment Opportunity (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), and the Know your Rights protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at hr@mvphealthcare.com
Please apply and learn more – including how you may become a proud member of our team.
