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Exchange/Commercial Compliance Specialist

Job Ref: 56721
Category: Professional
Location: 160 Water St. #3, New York, NY 10038
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $65,000.00
Salary Range: $65,000.00 - $75,000.00

About NYC Health + Hospitals

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview:

The Exchange/Commercial Regulatory Compliance Specialist reports to the Director of Regulatory Compliance.  The Specialist will support the oversight and management of Exchange/Commercial (Large Group/EP/CHIP/SHOP) regulatory compliance activities, including monitoring of all related regulatory guidance for compliance work plan activities, supporting the organization with corrective actions and regulatory disclosures, contributing to the annual Compliance risk analysis and Work Plan.  Ensuring the Exchange/Commercial Compliance plan and related Compliance training are accurate and updated.

Job Description

  • Serve as a subject matter regulatory compliance expert on Federal and State Base Exchange and Commercial health plan products.
  • Ensures that MetroPlusHealth is audit-ready, meets its regulatory reporting obligations, and responds to regulatory enforcement actions.
  • Assist Department Director in the development of the annual risk assessment and work plan, ensuring the gathering and provision of Exchange/Commercial regulatory compliance related information.
  • Identifies issues of non-compliance, provide support to business areas in conducting a root cause analysis and corrective actions, including guidance on methodology, identification of relevant regulatory requirements and any regulatory compliance context, and Compliance review.  Plays a critical role in driving the progress for corrective actions throughout the organization.
  • Supports the regular development and review of Regulatory Compliance policies and procedures for the general operation of the Plan’s compliance program and its’ related activities for Exchange/Commercial lines of business.
  • Conducts auditing and monitoring activities for Exchange/Commercial as outlined in Compliance Work Plan
  • Contributes quality and timely data for the materials prepared for both the Internal Compliance Committee Meetings and Audit and Compliance Subcommittee of the Board of Directors.  
  • Synthesizes regulatory guidance into Compliance activities and tracking related due dates and providing support to business areas completing deliverables.  
  • Coordinates the support for business areas in creating and updating monitoring metrics to assess continued compliance with regulatory requirements
  • Ensures proper investigation of all Exchange/Commercial regulatory compliance related issues.
  • Other duties as assigned or requested

Minimum Qualifications

  • A Bachelor’s degree preferred
  • Minimum 3 years experience at a Health Plan offering commercial insurance in a product management or compliance role

Licensure and/or Certification Preferred


Professional Competencies

  • Strong knowledge and understanding of the health insurance industry including underwriting rules and requirements, brokers, Marketplace Assistors, rate-setting, Flexible Spending Accounts, Labor Service Agreements, Health Savings Accounts, NYC Employee Assistance Programs, etc.
  • Experience with managed care with  Federal and/or State regulations, quality improvement and compliance oversight
  • Experience with Exchange required regulatory reporting, enrollment and marketing practices.
  • High-level of skill in leading interdepartmental and cross-functional strategy development; experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met. Simultaneously manage multiple projects