Healthcare Compliance Specialist at GEHA
About the position
GEHA (Government Employees Health Association, Inc.) is a nonprofit member association dedicated to providing medical and dental benefits to over two million federal employees, retirees, military retirees, and their families. Our mission is to empower federal workers to be healthy and well, and we pride ourselves on offering one of the largest medical and dental benefit provider networks available to federal employees in the United States. We are committed to diversity and inclusivity, ensuring that all employees feel valued and supported in their roles. In this position, you will be responsible for collaborating with various departments to ensure that processes, programs, and services are executed efficiently and in accordance with GEHA Plan benefits, OPM guidance, and accreditation standards. You will interact with both internal and external partners to oversee and govern compliance roles, ensuring that all operations align with regulatory requirements. Your duties will include monitoring a compliance program, communicating compliance information to leadership, reviewing vendor performance, providing staff education on changes to laws and regulations, and establishing best practices to support compliance. You will also conduct clinical and utilization data analysis for brochure changes, lead small-scale projects, and serve as an internal consultant to Medical Directors and staff regarding mandatory and recommended Plan Brochure changes. This role requires a proactive approach to ensure that medical benefit policies comply with OPM directives and regulatory requirements, while also allowing for independent judgment in complex assignments.
Responsibilities
Monitoring a compliance program and communicating compliance information to leadership.
,
Reviewing and reporting on vendor performance tools.
,
Providing staff education and training on any changes to laws and regulations.
,
Monitoring and reporting for noncompliance issues.
,
Establishing best practices to support compliance.
,
Performing ongoing clinical and utilization data analysis for brochure changes.
,
Leading small scale projects with functional partners that support appropriate integration and application of benefit.
,
Serving as internal consultant to Medical Directors and staff on mandatory and recommended Plan Brochure changes, and subsequent related process changes.
,
Making recommendations and ensuring medical benefit policy is compliant with OPM directives and regulatory requirements.
,
Conducting work assignments of increasing complexity, under moderate supervision with some latitude for independent judgment.
,
Performing other duties as assigned.
Requirements
Bachelor's degree (or international equivalent) in a health care field (e.g., health care policy, clinical guidelines development, nursing, health care administration, compliance).
,
4+ years of relevant experience in healthcare or a similar regulatory/investigational role.
,
Ability to build and maintain trust and productive relationships with internal stakeholders, clinicians, and others.
,
Knowledge of CPT, HCPCS, and ICD-10 purpose and application within the payer industry.
,
Ability to perform effective research and critical analysis using evidence-based literature and medical compendium.
,
Ability to analyze and communicate findings from research, including written summations of specific medical technology in areas of clinical effectiveness, measurable health outcomes, industry policy trends, and safety and appropriateness.
,
Ability to work independently and collaboratively in a team-oriented environment.
Nice-to-haves
Project Management experience.
,
CPC Certification and/or supporting degree.
,
5+ years' experience in healthcare closely related field, or similar regulatory/investigational roles in healthcare.
Benefits
Competitive pay/salary ranges
,
Incentive plan
,
Health/Vision/Dental benefits effective day one
,
401(k) retirement plan: company match - dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
,
Robust employee well-being program
,
Paid Time Off
,
Personal Community Enrichment Time
,
Company-provided Basic Life and AD&D
,
Company-provided Short-Term & Long-Term Disability
,
Tuition Assistance Program
Apply Now
GEHA (Government Employees Health Association, Inc.) is a nonprofit member association dedicated to providing medical and dental benefits to over two million federal employees, retirees, military retirees, and their families. Our mission is to empower federal workers to be healthy and well, and we pride ourselves on offering one of the largest medical and dental benefit provider networks available to federal employees in the United States. We are committed to diversity and inclusivity, ensuring that all employees feel valued and supported in their roles. In this position, you will be responsible for collaborating with various departments to ensure that processes, programs, and services are executed efficiently and in accordance with GEHA Plan benefits, OPM guidance, and accreditation standards. You will interact with both internal and external partners to oversee and govern compliance roles, ensuring that all operations align with regulatory requirements. Your duties will include monitoring a compliance program, communicating compliance information to leadership, reviewing vendor performance, providing staff education on changes to laws and regulations, and establishing best practices to support compliance. You will also conduct clinical and utilization data analysis for brochure changes, lead small-scale projects, and serve as an internal consultant to Medical Directors and staff regarding mandatory and recommended Plan Brochure changes. This role requires a proactive approach to ensure that medical benefit policies comply with OPM directives and regulatory requirements, while also allowing for independent judgment in complex assignments.
Responsibilities
Monitoring a compliance program and communicating compliance information to leadership.
,
Reviewing and reporting on vendor performance tools.
,
Providing staff education and training on any changes to laws and regulations.
,
Monitoring and reporting for noncompliance issues.
,
Establishing best practices to support compliance.
,
Performing ongoing clinical and utilization data analysis for brochure changes.
,
Leading small scale projects with functional partners that support appropriate integration and application of benefit.
,
Serving as internal consultant to Medical Directors and staff on mandatory and recommended Plan Brochure changes, and subsequent related process changes.
,
Making recommendations and ensuring medical benefit policy is compliant with OPM directives and regulatory requirements.
,
Conducting work assignments of increasing complexity, under moderate supervision with some latitude for independent judgment.
,
Performing other duties as assigned.
Requirements
Bachelor's degree (or international equivalent) in a health care field (e.g., health care policy, clinical guidelines development, nursing, health care administration, compliance).
,
4+ years of relevant experience in healthcare or a similar regulatory/investigational role.
,
Ability to build and maintain trust and productive relationships with internal stakeholders, clinicians, and others.
,
Knowledge of CPT, HCPCS, and ICD-10 purpose and application within the payer industry.
,
Ability to perform effective research and critical analysis using evidence-based literature and medical compendium.
,
Ability to analyze and communicate findings from research, including written summations of specific medical technology in areas of clinical effectiveness, measurable health outcomes, industry policy trends, and safety and appropriateness.
,
Ability to work independently and collaboratively in a team-oriented environment.
Nice-to-haves
Project Management experience.
,
CPC Certification and/or supporting degree.
,
5+ years' experience in healthcare closely related field, or similar regulatory/investigational roles in healthcare.
Benefits
Competitive pay/salary ranges
,
Incentive plan
,
Health/Vision/Dental benefits effective day one
,
401(k) retirement plan: company match - dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
,
Robust employee well-being program
,
Paid Time Off
,
Personal Community Enrichment Time
,
Company-provided Basic Life and AD&D
,
Company-provided Short-Term & Long-Term Disability
,
Tuition Assistance Program
Apply Now