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Regulatory Consultant IV - Evidence of Coverage Writer

Location Oakland, California Job Number 1066362 Date posted 05/03/2022
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Description:


Highly preferred to have a Juris Doctorate (JD)



The team within Health Plan Regulatory Services (HPRS) that is looking to fill this role is the California Contract and EOC Consulting (CCEC) team. CCEC is primarily responsible for developing and maintaining language for our commercial group and individual plan contracts and evidences of coverage (EOCs). CCEC must develop contract language that is legally enforceable, but still accessible to the average reader. CCEC also prepares filings to the Department of Managed Health Care, provides assistance to stakeholders regarding EOC interpretation, and consults on a variety of regulatory issues.




HPRS is 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.


HPRS is responsible for:



  • 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 Plan'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.





Essential Responsibilities:


HPRS is reponsible for Continued:



  • 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.  This includes managing relationships and maintaining communications with stakeholders at all levels and management and/or oversight of ongoing operations required for participation on public exchanges.


HPREO is responsible for:



  • 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.





Basic Qualifications:


Experience



  • Minimum nine (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.

  • Years spent in law school that resulted in a law degree may count as applicable job experience; JD will be counted in lieu of 3 years of experience.



Education



  • Bachelor's degree OR four (4) years of experience in a directly related field.

  • High School Diploma or General Education Development (GED) required.



License, Certification, Registration



  • N/A



 


Additional Requirements:



  • Years spent in law school resulting in a law degree may count as applicable job 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.



 


Preferred Qualifications:



  • JD

  • Technical contract writing/language technical abilities. 

  • Health care regulation experience

  • Strong experience and an intereste in health care are transferrable skills. 



 



Notes:




  • Position may be hired in NCal or SCal.



Primary Location: California,Oakland,1800 Harrison Additional Locations:

California Service Center, 3840 Murphy Canyon Rd., San Diego,California, 92123
Kaiser Permanente Building, 500 NE Multnomah St., Portland,Oregon, 97232
Marketing Sales Service and Admin, 3100 Thornton Ave., Burbank,California, 91504
Lowry Administration, 7901 E. Lowry Blvd. Ste 150 and 400, Denver,Colorado, 80230
AACC Sacramento, 3200 Arden Wy., Sacramento,California, 95825
Renton Administration - Adams, 2921 Naches Ave. SW, Renton,Washington, 98057
Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 08:00 AM Working Hours End: 05:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: NUE-PO-01|NUE|Non Union Employee Job Level: Individual Contributor Department: Oakland Reg - 2101 Webster - HP Mgr-Bene & Regltry Policy - 7016 Travel: Yes, 10 % of the Time Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.