Health Insurance Regulatory Specialist

ExamWorks is seeking a Health Insurance Regulatory Specialist to join the team 100% remote with monthly travel involved to conferences.

The Health Insurance Regulatory Specialist monitors and interprets state and federal regulations impacting health plans and prior authorization processes. This role ensures organizational compliance by maintaining regulatory databases, conducting audits, and collaborating with internal teams, legal, compliance, and clients. The position provides guidance during client acquisition and product development, leads educational efforts on compliance, and represents the company in regulatory and industry settings.

ESSENTIAL JOB FUNCTIONS

• Monitor and track both state and federal regulations affecting health plans and prior authorization processes; communicate updates on proposed legislation and regulatory changes to the business
• Develop and maintain a regulatory compliance database and conduct internal audits to ensure adherence to applicable laws and invite areas for improvement
• Collaborate with legal compliance, clients, and internal teams to resolve regulatory issues and guide product strategies that align with current and anticipated regulations
• Provide regulatory guidance during the client acquisition process; educate clients on compliance requirements through meetings, workshops, and webinars
• Advise on product development initiative to ensure regulatory compliance and identify opportunities to enhance offerings based on regulatory standards
• Maintain relationships with regulatory agencies, industry groups, and stakeholders; represent the company at conferences and relevant meetings to stay informed and advocate for compliance; travel as required
• Manage and/or complete a wide variety of other miscellaneous projects as the business may otherwise require

• Bachelor's degree required
• 5+years of recent experience in the health insurance compliance space required
• Familiarity with Utilization Management ("UM") and its regulatory requirements preferred
• MBA preferred; Certified in Healthcare Compliance (CHC), Certified Professional in Healthcare Quality (CPHQ), or similar credential preferred.
• Strong research and data analysis skills required
• Must have strong organizational skills with the ability to prioritize and manage multiple projects simultaneously
• Must have strong understanding of state and federal healthcare regulations, particularly those related to health plans and prior authorization processes
• Must have proven ability to analyze and interpret regulatory guidelines and legislation
• Must have experience in product development and strategy within a regulated industry
• Ability to build and maintain positive relationships with clients and regulatory bodies
• Must be proficient in Microsoft Office Suite and other standard business software
• Must be able to demonstrate commitment to accuracy, quality, and continuous improvement
• Must have strong analytical and problem-solving skills
• Ability to travel as necessary
• Must be able to maintain confidentiality

ABOUT US

ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services. Our clients include property and casualty insurance carriers, law firms, third-party claim administrators and government agencies that use independent services to confirm the veracity of claims by sick or injured individuals under automotive, disability, liability and workers' compensation insurance coverages.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.

Equal Opportunity Employer - Minorities/Females/Disabled/Veterans

ExamWorks offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.

health insurance

health insurance

regulatory

regulatory

utilization management

utilization management

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