Regulatory and Reporting Specialist

PacificSource Health Plans

Regulatory and Reporting Specialist supporting all aspects of Grievance and Appeals compliance programs for Medicare and Medicaid. Interfacing with multiple departments to ensure compliance and conduct audits.

Posted 6/26/2026full-timeRemote • 🇺🇸 United StatesJuniorMid-Level💰 $44,982 - $71,972 per yearWebsite

About the role

Key responsibilities & impact

Support all aspects of the Grievance and Appeals (G&A) compliance program for Medicare and Medicaid lines of business
Assume the primary role of interfacing with the Compliance department, Auditors, Vendors and G&A staff for purposes of monitoring and ensuring compliant operations
Interface with the Compliance Department and Fraud, Waste and Abuse teams to evaluate and address fraudulent activities impacting the G&A Department
Conduct internal audits, support external audits, develop policies and procedures, and ensure departmental compliance
Develop auditing and monitoring plans to assess compliance with all State, Federal and internal business rules and regulations
Serve as an inter-departmental liaison for compliance and FWA activities
Inform all business operations and workflow decisions to ensure that programs are compliant with State, Federal and internal business rules and regulations
Be fully informed and ensure compliant processes are in place on all G&A business operations
Conduct frequent monitoring activities of all G&A business operations, publish results and report out to G&A Leadership, Compliance Department, quality committees and other PacificSource leadership teams as applicable
Respond to all compliance related inquiries from internal Compliance Department Staff and external Auditors

Requirements

What you’ll need

Minimum of two years of Grievance and Appeals related health insurance experience required
Strong preference for experience in auditing or compliance related role
High school diploma or equivalent required; Bachelor's degree preferred
Strong computer skills
Excellent verbal and business writing skills
Excellent public relations skills
Good understanding of Medical Terminology required
Requires ability to define and prioritize problems and manage workload without direct supervision

Benefits

Comp & perks

Flexible telecommute policy
Medical, vision, and dental insurance
Incentive program
Paid time off and holidays
401(k) plan
Volunteer opportunities
Tuition reimbursement and training
Life insurance
Options such as a flexible spending account

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

auditingcomplianceGrievance and Appealsinternal auditsexternal auditspolicy developmentmonitoring plansMedical Terminology

Soft Skills

verbal communicationbusiness writingpublic relationsproblem definitionworkload management