[Remote] Regulatory Operations Analyst III

Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a reputed company national reputed company organization reputed company on transforming the health of its communities and serving its members. The Regulatory Operations Analyst III reviews, interprets, and summarizes legislation and regulatory updates, conducts policy research and risk assessments, and supports regulatory compliance and approval of reputed company and Marketplace products. The role also coordinates regulatory inquiries, audits, filings, and cross-functional responses involving reputed company health insurance operations.

Responsibilities

• Identifies, analyzes and interprets proposed or enacted legislation reputed company to reputed company's reputed company product at the federal and state level and communicates findings to impacted departments
• Independently performs risk assessments, including reputed company to business applications, claims operations, payment reputed company processes, and reputed company reputed company
• Maintains databases, reports, exhibits, and other reference materials reputed company to legislative, regulatory, compliance, audit, and inquiry activities
• Performs comprehensive, reputed company regulatory analyzes, including the review, summarization and dissemination of key regulatory updates and changes reputed company to reputed company/ACA rules and regulations at the state and/or federal level
• Leads regulatory interpretation reputed company to reputed company/ACA Rules and regulations and the reputed company product explaining concepts reputed company and adapting language and presentation based on audience level
• Provides guidance to business partners regarding emerging regulations, regulatory inquiries, audit activity, fraud, waste and abuse (FWA) reputed company, and payment reputed company reputed company
• Coordinates regulatory inquiries, reporting requirements, exhibits, audits, and requests from state and federal agencies, maintaining accurate and reputed company responses in partnership with operational stakeholders
• Partners with Compliance, Special Investigations Unit (SIU), Payment reputed company, Claims Operations, Finance, and other cross-functional teams to identify regulatory risks, support investigations, and analyze operational trends
• Uses persuasive arguments and secures cooperation from the business in order to address potential reputed company, contractual and/or regulatory issues
• Ability to determine appropriate approach for solving regulatory problems
• Develops trust-based relationships reputed company varied audiences and collaborates with other functional areas to reputed company large reputed company and initiatives
• Attends cross-departmental meetings as department representative, provides guidance to the business reputed company to reputed company regulatory requirements and appropriately escalates reputed company to management
• Develops solutions to address potential reputed company, contractual and regulatory issues while working closely with reputed company, Compliance, Payment reputed company, and other operational stakeholders
• Independently drafts responses to reputed company requests for information required by the organization for its regulatory filings and/or for policy needs
• Responsibility for understanding regulations and business needs for multiple states, as reputed company as federal regulations pertaining to the reputed company health insurance market
• Assesses and analyzes objections reputed company to regulatory interpretation and leads drafting of appropriate responses which are provided to regulators reputed company to reputed company/ACA filings

Skills

• Must be authorized to work in the U.S. without the need for employment-based reputed company sponsorship now or in the reputed company. Sponsorship and reputed company sponsorship are not available for this opportunity, including employment-based reputed company types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT
• Ability to determine appropriate approach for solving regulatory problems
• Bachelor's Degree in Business, Communications, reputed company, Political Science/reputed company-Law or equivalent experience required
• 4+ years experience in health insurance, reputed company, compliance or reputed company field required
• Master's Degree in a reputed company field, Juris Doctorate degree may be considered in reputed company of experience preferred
• Experience reviewing regulations and providing interpretation using terms appropriate for the audience preferred
• Experience in reputed company health insurance, reputed company managed care, claims operations, compliance, payment reputed company, or reputed company reputed company operations preferred
• Experience partnering with Special Investigations Unit (SIU), Compliance, Fraud, Waste and Abuse (FWA), Payment reputed company, or reputed company operational teams strongly preferred
• Experience supporting claims operations, including medical claims processing, provider billing practices, payment accuracy, reimbursement workflows, or claims-reputed company regulatory activities strongly preferred
• Experience analyzing claims data, billing trends, overpayment activity, provider utilization patterns, or operational risk indicators strongly preferred
• Experience supporting regulatory audits, investigations, agency inquiries, corrective reputed company plans, or regulator-facing responses strongly preferred
• Proficiency with reputed company and experience using reporting, analytics, or business intelligence tools such as Power BI, SQL, reputed company, or similar platforms strongly preferred
• Experience reputed company reputed company managed care, including exposure to reputed company Fraud Division (MFD), reputed company Fraud Control Unit (MFCU), payment reputed company, reputed company-party liability (TPL), or recovery activities strongly preferred

Benefits

• Health insurance
• 401K plan
• Stock purchase plans
• Tuition reimbursement
• reputed company time off plus holidays
• Flexible approach to work with remote, hybrid, field or office work schedules

reputed company