Job Details

The Regulatory Specialist is responsible for ensuring organizational compliance with federal and state regulatory requirements related to Medicare Advantage and ACA-compliant individual and small group health plans. This position plays a critical role in interpreting new and existing regulations, coordinating with internal teams to implement necessary changes, and managing regulatory filings and communications with oversight agencies such as CMS and state Departments of Insurance (DOIs).

This position is responsible for monitoring regulatory developments and policy changes, analyzing their impact on business operations, preparing filings, and collaborating with internal stakeholders to operationalize requirements and maintain compliance with CMS and state laws and mandates. The ideal candidate has a strong understanding of health insurance laws (e.g., ACA, HIPAA, CMS, state DOI regulations) and experience working with regulatory bodies.

Job Description

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
• Monitor federal and state regulatory changes, analyzing operational impact and  providing analysis for internal stakeholders, including internal training, dissemination and distribution of regulatory communications to affected business units.
• Interpret bid and filing requirements, working  with cross-functional teams to advise on implementation of new programs and initiatives.
• Prepare and ensure timely and accurate submission of regulatory bid, binder and state filings, license renewals, and responses to state Departments of Insurance (DOIs), Centers for Medicare & Medicaid Services (CMS), and other oversight agencies.
• Collaborate with internal departments to ensure product benefits and communication materials meet requirements.
• Maintain accurate records of regulatory correspondence, provide distribution to affected departments, and ensure timely follow-up on required actions.
• Draft and update compliance policies and procedures specific to regulatory department.
• Serve as a subject matter expert (SME) for regulatory requirements and provide training and guidance to internal teams.
• Serve as a liaison between the company and regulatory agencies.
• Ensure Medicare Advantage plans meet all CMS regulations, including Part C & D requirements, marketing guidelines, network adequacy, and reporting requirements.
• Ensure ACA plans meet all state and federal mandates, including QHP certification requirements, essential health benefits, and standardized plan structures.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Competencies (Knowledge, Skills, and Abilities Required):

• Strong analytical, research and critical thinking skills.
• Excellent written and verbal communication abilities.
• Attention to detail and high level of organizational skills.
• Ability to manage multiple tasks and meet deadlines in a fast-paced environment.
• Proficiency with Microsoft Office Suite. 
• Experience with HPMS, SERFF and HIOS systems is a plus.
• Comfortable working in a cross-functional and deadline-driven environment.

Minimum Education and Experience Requirements:

Education:

• Bachelor’s degree in public health, Business Administration, Health Policy, Law, or a related field.
• Juris Doctor (JD) or Master’s degree in a relevant field is a plus.

AND

Experience:

• 3–5 years of experience in a regulatory or compliance role within the health insurance, healthcare, or managed care industry.
• Knowledge of applicable federal and state health insurance regulations, including ACA, CHIP, HIPAA, Medicare, and Medicaid.
• Experience dealing with regulatory agencies such as CMS and state DOIs.
• A strong understanding of ACA and Medicare benefits and regulations, including QHP and Medicare Advantage requirements and state/federal Exchange operations.
• Experience preparing or supporting CMS and DOI filings is strongly preferred.

Additional Information

Please note this job description is not designed to cover or contain a comprehensive listing of

activities, duties, or responsibilities that are required of the employee for their job. Duties,

responsibilities, and activities may change at any time with or without notice.

Compliance Statement:  Compliance with all applicable rules, regulations and laws is a condition of employment.  Employees must read and sign the Code of Conduct and be expected to perform their duties ethically and honestly.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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