Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

• Maintain expert knowledge of all relevant legislative and regulatory health plan requirements to ensure that plan activities are in compliance. Serve as SME on regulations related to Horizon's LOBs, reporting requirements and required filings.

• Interface with Enterprise leaders and provide direction for operations through consultative support of regulatory compliance matters.

• Identify, evaluate, and recommend solutions to complex compliance issues consistent with regulatory requirements.

• Lead compliance meetings with business teams to discuss matters related to regulatory non-compliance; oversee internal investigations and any resulting corrective action plans.

• Oversee monitoring of multiple information sources related to changes in regulatory compliance program requirements for Horizon's LOBs; Develop and deploy mechanisms for monitoring information sources.

• Ensure new and revised requirements are accurately reviewed, interpreted, summarized, and communicated to the business using multiple distribution methods.

• Develop and implement a comprehensive compliance program that is well designed and executed to ensure regulatory compliance and expectations, including appropriate policies, procedures, reporting, training, and resource allocation.

• Develop and effectively implement compliance reporting including key metrics, monthly dashboards, regulatory notices and corrective action plan tracking and trending. Compiles, analyzes, prepares, and distributes compliance dashboards and other reports based on established divisional and departmental reporting standards.

• Establishes and maintains positive, collaborative relationships with internal business partners, external regulatory agency representatives and regulatory/compliance consultant groups. Serves as a Horizon representative to regulatory agencies, internal and external auditors, and external legal counsel for Compliance.

• Execute the annual risk assessment, which includes: updating and distributing the risk assessment questionnaire, reviewing responses, interviewing key stakeholders, and analyzing all collected information to evaluate and assess risks.

• Promote activities to foster compliance awareness through various modes of publicity and events.

• Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.

• Accountable for ensuring vendor compliance for Horizon and its subsidiaries. Serve as a subject matter expert on vendor regulations and guidelines from CMS and DMAHS.

• Responsible for monitoring delegated entities to ensure there is an effective compliance program, including: acceptable Standards of Conduct, conducting monthly OIG/GSA screening, compliance with all applicable training requirements, monitoring and auditing of downstream entities, appropriate reporting mechanisms for fraud, waste and abuse and compliance issues, and HIPAA Privacy controls.

• Recommend and prepare revisions to the Vendor Code of Conduct, and other enterprise-wide compliance standards, including annual maintenance and updates to delegated vendor-specific policies and operating procedures related to third party vendors.

• Represent Vendor Compliance at all management meetings including the Delegate and Vendor Oversight Committee (Government Programs and Commercial) and Enterprise Vendor Management Committees.

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

• High School Diploma/GED required.

• Bachelor degree preferred or relevant experience in lieu of degree.

• Requires a minimum of seven (7) years of regulatory compliance experience in health care or legal.

• Requires three (3) years of managerial experience or project/program management role, or lead role in a compliance, regulatory, or legal function in a health care environment.

• Prefers experience working with regulatory agencies.

Preferred:

• Certified Compliance & Ethics Professional Certification (CCEP) - Compliance Certification Board

• Certified in Healthcare Compliance (CHC) - Compliance Certification Board

• Leadership Professional in Ethics & Compliance (LPEC) - Ethics and Compliance Institute

• Knowledge of the sources of legal and regulatory requirements relevant to state and federal requirements.

• Governance, risk, and compliance (GRC), audit, compliance, or other business intelligence-based software preferred.

• Knowledge of the Federal and State regulatory environment with emphasis on health insurance exchanges, qualified health plans, and the Affordable Care Act.

• Solid understanding of compliance issues and healthcare risk areas applicable to Commercial insurance.

• Knowledge of the Federal and State regulatory environment with emphasis on CMS, DOBI and DMAHS requirements.

• Knowledge of CMS regulations, including Medicare Marketing guidelines.

• Knowledge of the Federal and State regulatory environment with emphasis on Medicaid and NJFamilyCare, Managed Long-Term Services and Supports, the New Jersey False Claims Act, Fraud, Waste and Abuse, Anti-Kickback law and State Medicaid requirements.

• Ability to work independently with minimal supervision or direction.

• Excellent at organizing, managing, and handling competing projects with a proven ability to meet tight deadlines in a fast-paced environment

• Excellent communicator, both written and oral, to act as a cross-functional business partner.

• Excellent facilitation, active listening, and presentation skills. Experienced in developing high-impact presentations and presenting effectively to all levels within the organization.

• Strong critical thinking skills and the ability to apply an analytical approach to regulatory research and issue remediation.

• Strong persuasion/negotiation and interpersonal relationship skills and the ability to effectively interact and collaborate with individuals at all levels within the organization.

• Problem solving acumen. Ability to identify potential noncompliance issues, obtain information to clarify and describe issue, exercise sound decision-making, resolve problems using appropriate risk treatment, and leverage appropriate escalation pathways.

• Strong compliance orientation, coupled with healthcare process expertise.

Travel to other office locations may be required.

Salary Range:

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:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

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.