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Compliance Specialist HealthSpring Medicaid

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Bedford, TX

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Description Responsible for performing Medicaid and MMP (Medicare and Medicaid Plan) monitoring activities and internal audit for the Cigna-HealthSpring (CHS) Medicaid Compliance Department, with emphasis in various areas such as Claims, Appeals and Grievance, Provider Data Accuracy, and Service Coordination. Collaborates with CHS Compliance colleagues and business partners to drive process improvements and ensure successful remediation of corrective actions. Forges and maintains positive working relationships with business owners (BOs), management, regulators and compliance colleagues. Demonstrates the ability to influence business partner and\/or staff behavior at whatever level and to whatever extent is needed. Provides day-to-day regulatory and compliance guidance and support to the BOs.To be successful, this candidate must exhibit superior analytical, verbal\/written communication and collaborative skills, as well as the ability to excel in a dynamic, fast-paced environment. The candidate has to demonstrate solid command of the Medicaid and MMP rules. This Compliance team member must be adept at working with a variety of internal and external stakeholders. S\/he will promote an enterprise-wide culture of compliance and provide first-rate support within the Compliance Department and across the business units. Reports to the Medicaid Compliance Manager who has responsibility for monitoring and internal audit within the Compliance Department\u2019s Medicaid Monitoring and Internal Audit Unit; Monitors Claims and Explanation of Benefits (EOBs) or Explanation of Payment (EOPs) to confirm compliance with requirements, including, but not limited to: EOB and EOP generation, content and accuracy; Perform full and\/or limited audit of the internal business areas from planning , testing, reporting to closure to determine if CHS is in compliance with federal and state laws, rules and regulations as well as internal policies and procedures; Review, approve, and submit State required marketing materials ensuring compliance with federal and state marketing regulations; Prepare draft, final, and exceptions reports from monitoring and internal audit results; Provides subject matter expertise through research and analysis in response to day-to-day business issues related to Medicaid and MMP regulatory requirements; Collaborates with the Compliance Department\u2019s Medicaid and Medicare compliance colleagues and various Business Owners to drive process improvements and ensure that corrective action plans are tailored and appropriate for the deficiencies identified; Provides meaningful and appropriate reporting metrics to support the Compliance Monitoring and Internal Audit Program; Maintaining tracking and trending document after each reporting period to analyze any discrepancies and advise the appropriate area(s) to correct; Attend industry meetings, etc.; Performs other duties as assigned by the Medicaid Compliance Manager and\/or the Senior Compliance Specialist. Qualifications Bachelor\u2019s degree preferred; Minimum of three to five years of related experience with Medicaid and MMP regulations and the Medicaid and\/or Medicare Managed Care Manual; Experience in managed care setting preferred; Strong attention to detail, and analytical skills required; and Strong and confident oral and written communication skills Qualified applicants will be considered for employment without regard to age, race, color, religion, national origin, sex, sexual orientation, gender identity, disability, veteran status. Need an accommodation? Email:

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Company Profile
Cigna works with employers and organizations around the world helping employees stay healthy and on the job. We work closely with brokers and consultants to develop innovative programs, help individuals and families improve their health, well-being and sense of security—and lower their medical costs. And, Cigna provides access to a global network of local physicians and hospitals—as well as 24/7/365 live customer service.

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