CareFirst BlueCross BlueShield is seeking a Regulatory Compliance Analyst to conduct independent analysis regarding provider open negotiation requests and independent dispute resolution initiations. The role involves overseeing the dispute resolution process, ensuring compliance with federal regulations, and contributing to the company's success through effective communication and problem-solving.
Responsibilities
- Review and analyze to determine eligibility and to develop substantive argument to support CareFirst CIDRE selections/eligibility and offers on IDRs
- Oversees the end-to-end process of the billing vendors and dispute resolution claim submission and payment requests. This includes the maintenance of the NSA tracking database and claims resolution from start to finish. Monitors claims, identify trends, presents opportunity areas, and prioritizes initiatives for performance improvement. Tracks outcomes of payment resolution and negotiated claims to ensure goals are met
- Provide interpretation of regulations and regulatory rules/guidelines, including NSA and state reimbursement laws, to ensure compliance with federal requirements with the NSA IDR process
- Improves NSA knowledge and other appropriate regulatory investigation job knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; benchmarking state-of-the-art practices; participating in professional societies
- Contributes to NSA IDR and company success by welcoming related, different, and new requests; helping others accomplish job results
Skills
- Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience
- 1 year experience in a regulatory, compliance or customer service role
- Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
- Ability to convey information in a clear, concise, and logical manner
- Ability to effectively convey information to others
- Excellent critical thinking and communication skills both written and verbal
- Consistently maintains highly professional written and verbal interaction with all levels of staff within the company and with members of regulatory agencies
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence
- Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging
- Must be eligible to work in the U.S. without Sponsorship
- Demonstrated experience with Excel, Salesforce, and claims processing systems
Benefits
- Comprehensive benefits package
- Various incentive programs/plans
- 401k contribution programs/plans
Company Overview
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