Horizon Blue Cross Blue Shield of NJ Medicare Program Specialist in Newark, New Jersey

Medicare Program Specialist

Job ID: JV052018-11630

Description:

This position administers and coordinates the functions associated with compliance and regulatory guidelines related to senior market member materials and marketing initiatives. This includes the development and maintenance of standard operating policies and procedures. This position will work with the business areas to ensure compliance with the Centers for Medicare & Medicaid Services (CMS), Medicare Marketing Guidelines (MMG) for Medicare Parts C and D, and the additional Division of Medical Assistance and Health Services (DMAHS) requirements related to the dual regulatory oversight and review process for Horizon-s Special Needs Plan business. Collaborates with other business areas daily to foster a compliant culture for all marketing materials and activities which include but are not limited to sales initiatives, care management programs and member engagement related to Medicare star ratings.

  • Serve as the primary subject matter expert on the CMS (Center for Medicare & Medicaid Services) Medicare Marketing Guidelines (MMG) for Horizon's Medicare products. Establishes and maintains a comprehensive understanding of all CMS and State requirements related to Medicare Advantage, Medicare Part D and Medicaid requirements, for the special needs plan, with respect to marketing and related materials.

  • Supports all areas of the company in the evaluation of Medicare marketing and other member communications strategies and initiatives to ensure compliance with CMS and New Jersey DMAHS (Division of Medical Assistance and Health Services) requirements, as applicable. Evaluates simple to complex marketing initiatives and exercises independent judgment about the compliance status of such initiatives. Solicits guidance from Legal Affairs, if needed.

  • Responsible for HPMS (Health Plan Management System) submission and tracking of all applicable material through the CMS and DMAHS approval processes.

  • Responsible for managing to and reporting on the CMS file & use compliance standard.

  • Coordinate the dual regulatory process for SNP program materials between CMS and DMAHS.

  • Develop and maintain tools to facilitate and report on the internal review of materials (e.g. internal CMS Submission Database; SharePoint site functionality) consistent with evolving CMS and DMAHS marketing guidelines.

  • Actively participates in the annual product implementation which includes providing guidance on and facilitating review and approval of all materials related to the annual product implementation such as annual notices of change, evidence of coverage documents, formulary and provider related material and model operational letters. Also provides input into the annual project plan to support the implementation so that CMS due dates are met. Proactively identify improvement areas and take appropriate action to address any issues. Conducts monitoring and oversight of marketing review performance, including monthly reports of key metrics to senior management. Monitors materials being used in the operations to ensure compliance with the versions on file with regulators. Documents results of monitoring reviews and works to address any identified issues.

  • Develop and update Standard Operating Policies and Procedures (SOP) which impact the marketing review process and compliance. Educate stakeholder on these SOPs.

  • Develops and maintains collaborative relationships with state and federal regulators in support of Horizon government programs business objectives.

  • Assist in the coordination of responses required due to CMS Marketing Surveillance activity.

Core Competencies:

Personal and professional attributes that are critical to successful performance:

  • Adaptability, Communicating with Impact, Customer Focus, Developing Self & Others, Driving for Results.

Education/Experience:

  • Requires a Bachelor's degree.

  • Requires a minimum of five (5) years in a health insurance or managed care environment.

  • Prefers a minimum of three (3) years’ experience in government programs compliance, marketing, communications or operations.

  • Strong interpersonal and communication skills, including skills in negotiating and influencing others.

Knowledge:

  • Prefers knowledge of state and federal laws and regulations, including CMS, DOBI and DMAHS requirements.

  • Prefer knowledge of Horizon BCBSNJ senior market product portfolio.

  • Requires working knowledge of personal computers and supporting software in Windows-based environment including MS Office Products and email application systems.

  • Requires knowledge of the health insurance industry.

  • Knowledge of CMS regulations, including Medicare Marketing guidelines is preferred.

  • Must be detail oriented and results focused.

Skills and Abilities:

  • Strong communication skills (verbal, written and presentation).

  • Requires ability to read complex statutes and regulations and interpret them in order to identify compliance needs/risks, etc.

  • Analytical and Problem Solving.

  • Teamwork.

  • Listening.

  • Flexibility/Adaptability.

  • Decision Making.

  • Results Oriented.

  • Information Gathering.

  • Attention to Detail.

  • Integrity/Trust.

  • Influencing/Persuading.

Travel (If Applicable):

  • Very limited.

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.

Requirements:

EducationBachelors

Job LevelIndividual Contributor

ExpertiseLegal & Compliance

Job TypeFull Time

LocationNewark, NJ

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.