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011250 CCA-Claims

Position Summary:

Reporting to the Director, Claims Operations & Quality Assurance, the Regulatory Compliance & Audits Sr. Specialist II is responsible for ensuring CCA’s operational compliance with state and federal healthcare regulations, particularly MassHealth (Massachusetts Medicaid) and CMS Medicare requirements. This role is housed within the Claims Operations & Quality Assurance team and works closely with Cognizant (TPA) to drive configuration changes, submit and track system change requests, and prepare for audits and regulatory reviews. This role is critical to supporting CCA’s internal handling of all regulatory audits and maintaining alignment with evolving state and federal requirements.

Supervision Exercised:

• No, this position does not have direct reports.

Essential Duties & Responsibilities:

Regulatory Compliance & Monitoring

• Monitor CMS and MassHealth regulations, bulletins, and contractual updates to ensure operational alignment.

• Translate regulatory updates into operational actions, collaborating with Claims, Appeals, UM, and Provider Services.

• Conduct internal audits and retrospective reviews to identify areas of risk or non-compliance.

• Track internal audit findings and facilitate resolution through Corrective Action Plans (CAPs).

Audit Readiness & Execution

• Serve as point of contact for CMS and MassHealth audit activities and mock audits.

• Coordinate audit universe creation, file sampling, and audit submission timelines.

• Assist in training internal staff on audit protocols and documentation standards.

• Document and track all regulatory inquiries, escalations, and resolutions.

Change Request Management & System Configuration

• Draft detailed ServiceNow change requests in collaboration with Cognizant for updates to Facets configuration based on compliance findings or regulatory needs.

• Participate in validation and UAT (user acceptance testing) for regulatory-related system updates.

• Track the implementation lifecycle of configuration changes to ensure regulatory alignment.

• Maintain audit trail of all configuration changes related to CMS/MassHealth guidance.

Cross-Functional Collaboration

• Act as a liaison between Compliance, Claims Operations, Cognizant, and Configuration teams.

• Participate in weekly operational meetings and surge protocol reviews.

• Respond to compliance inquiries from internal teams regarding benefit design, denial logic, or claims workflows.

• Assist in the review of policy and procedure documents to ensure compliance language is current.

Governance & Reporting

• Maintain internal compliance dashboards and contribute to ELT-level reporting.

• Support policy governance by helping draft and update SOPs tied to regulatory processes.

• Assist with complaint resolution involving state or federal regulatory bodies.

Working Conditions:

• Standard office conditions.

Required Education (must have):

• Bachelor’s degree required

Desired Education (nice to have):

• Master’s in Health Administration, Public Policy, or a related field preferred.

Required Experience (must have):

• 5+ years in healthcare compliance, regulatory affairs, or claims audit.

• Experience working with TPA partners (e.g., Cognizant) and submitting Facets configuration changes highly preferred.

Desired Experience (nice to have):

•

Required Knowledge, Skills & Abilities (must have):

• Strong working knowledge of MassHealth ACO/MCO requirements and CMS (Medicare Advantage) regulations.

• Expertise in 42 CFR Part 422, MassHealth provider manuals, transmittals, and audit protocols.

• Proficiency in writing clear change requests and translating regulations into system actions.

• Excellent organizational, documentation, and analytical skills.

• Ability to manage competing priorities under deadline in a cross-functional environment.

Required Language (must have):

• English

Desired Knowledge, Skills, Abilities & Language (nice to have):

• Facets (Core Claims Platform)

• ServiceNow (Change Request Management)

• Salesforce (Dispute/Compliance Tracking)

• Microsoft Teams, Outlook, Excel

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.