Regulatory and Reporting Specialist

PacificSource Health Plans

Regulatory and Reporting Specialist supporting compliance for Medicare and Medicaid programs and interfacing with departments to ensure compliant operations. Collaborating with teams to develop policies and auditing plans for compliance assurance.

Posted 7/22/2026full-timeFlorida • 🇺🇸 United StatesJuniorMid-Level💰 $44,982 - $71,973 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in compliance program management for Medicare and Medicaid, including conducting audits, developing policies, and ensuring adherence to regulations. Strong communication skills are essential for liaising with various departments and stakeholders to maintain compliance and address inquiries effectively.

Highest-signal resume keywords

Compliance Program ManagementInternal AuditsMedicare RegulationsMedicaid RegulationsMedical Terminology

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Compliance MonitoringPolicy DevelopmentAudit SupportFraud, Waste, and Abuse EvaluationRegulatory Compliance

Soft Skills

Excellent Verbal CommunicationBusiness Writing SkillsPublic Relations SkillsProblem Definition and PrioritizationWorkload Management

Tools & Technologies

Helpdesk OperationsOperational Performance Reports

Industry Keywords

Health InsuranceState RegulationsFederal RegulationsOIG StatusCompliance Inquiries

About the role

Key responsibilities & impact

Support all aspects of our Appeals and Grievance (A&G), Care Management (CM), and Utilization Management (UM) compliance program for Medicare, and Medicaid lines of business
Assume the primary role of interfacing with the Compliance department, Auditors, Vendors and 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 these departments
Conduct internal audits, support external audits, develop policies and procedures, and ensure departmental compliance
In partnership with Compliance staff and leadership, 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 an internal business rules and regulations
Be fully informed and ensure compliant processes are in place on all business operations, including but not limited to: business processes, OIG status, FWA programs, Helpdesk operations including call monitoring, Communication strategies, Website publications, Claims adjudication, and all vendor managed programs
Maintain a current working knowledge of all applicable Medicare, and Medicaid rules and regulations including assessment, impact report and training on any new rules or regulations to all impacted departments
Conduct frequent monitoring activities of all business operations, publish results and report out to 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 in a timely, professional and accurate manner to ensure minimal organizational and operational impact
Work collaboratively with leadership to produce and monitor department policies and procedures as applicable and ensure their regular maintenance to reflect new practices and guidance
Provide interpretation, training, and implementation of Medicare, and Medicaid regulations and communicate them appropriately with respective departments and teams
Attending weekly meetings; review and approve external communications; and monitor operational performance reports
Support ongoing communication efforts.
Maintaining compliant members, departments, and provider communications
Keeping letters and other member communications up to date with compliance guidance and best practices

Requirements

What you’ll need

Minimum of 2 years of compliance-related experience required
Strong preference for health insurance experience
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