Director - Regulatory Operations & Commercial Relationship Executive
Full Time
Albuquerque, NM 87113
Posted
Job description
Overview:
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
The Director, Regulatory Operations & Commercial Relationship Executive is responsible for management of ongoing regulatory requirements of state contracts for the Medicaid business, federal requirements (CMS) for the Medicare lines of business, and state insurance requirements for commercial lines of business.
The Director serves as the relationship executive between PHP and the Office of Superintendent of Insurance (OSI).
The Director is accountable for:
Qualifications:
Preferred Qualifications:
Responsibilities:
We offer more than the standard benefits!
Learn more about our employee benefits:
https://www.phs.org/careers/employee-benefits/Pages/default.aspx
Why work at Presbyterian?
Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.
About Presbyterian Healthcare Services
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
About Our Regional Delivery System
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.
New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
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The Director, Regulatory Operations & Commercial Relationship Executive is responsible for management of ongoing regulatory requirements of state contracts for the Medicaid business, federal requirements (CMS) for the Medicare lines of business, and state insurance requirements for commercial lines of business.
The Director serves as the relationship executive between PHP and the Office of Superintendent of Insurance (OSI).
The Director is accountable for:
- ensuring regulatory and contractual requirements are identified, analyzed, and operationally implemented.
- providing regulatory guidance to senior management and operational areas to support the development of appropriate processes, policies, procures and guidelines to ensure operational readiness in conformity with state and federal regulatory requirements for all lines of business.
For the commercial line of business, the Director serves as the primary point of contact and strategic relationship manager with OSI.
Qualifications:
- Bachelors degree
- 5-8 years of increasingly responsible management positions in health plan operations at a leadership level.
- Prior health plan (HMO/Insurance) setting, with product and operational knowledge of Medicare, Medicaid, and Commercial.
- Strong understanding of the operational complexities and regulatory requirements as they relate to administering health plan benefits.
- Demonstrated problem-solving, decision-making and leadership abilities including the capacity to produce results in a complex, matrix setting.
- Excellent verbal, written, presentation and interpersonal skills
Preferred Qualifications:
- 5 years of experience in a leadership role in Operations (Compliance, Claims, Call Center, Billing & Enrollment) of a managed care organization.
Responsibilities:
- Accountable for leading the team responsible for identifying new regulatory requirements that impact PHP operational areas across all product lines, manages day-to-day operational aspects of the team and pending projects, effectively communicates to team members, delegates tasks and responsibilities to appropriate resources.
- Accountable for building a regulatory operations team that can operate effectively in a matrix environment and serves as a mentor to management and staff.
- Accountable for managing the strategic relationship with OSI and building an ongoing strong and trusted relationship with OSI.
- Provides direction and support to appropriate business areas to ensure regulatory and contractual requirements are properly implemented. Acts proactively in identifying potential regulatory and operational issues, and appropriately escalates issues to leadership.
- Oversees and helps coordinate regulatory filings and responses to regulatory agencies.
- Leads the efforts that monitors, researches and analyzes emerging state and federal laws and regulations, and takes the lead on monitoring federal rulemaking that impacts health plan operations.
- Serves on the enterprise Government Relations Committee and various other governance committees, work groups and other teams as needed, most notably related to implementing new regulatory or contractual requirements.
We offer more than the standard benefits!
Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!
Learn more about our employee benefits:
https://www.phs.org/careers/employee-benefits/Pages/default.aspx
Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.
Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.
About Presbyterian Healthcare Services
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
About Our Regional Delivery System
Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
New Mexico continues to grow steadily in population and features a low cost-of living.
Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.
New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
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