This job implements the Medicare, Medicaid or Marketplace Compliance Program. This leadership role makes sure the business is properly following the growing number of laws, regulations, and other requirements set forth by the government for managed care organizations. Leads the further development, implementation and maintenance of an effective government compliance and risk management program. The incumbent is a trusted business partner who provides compliance advice and guidance on federal and state government regulations governing Programs. Defines the program structure, educational/training requirements, reporting and compliance mechanisms, response and correction procedures and compliance expectations for all personnel, first tier, downstream, and related (FDR) entities that support core functions of the government program contracts.
- Monitor regulatory agencies for changes in laws, requirements etc. relevant to the government program and communicate changes to affected business unit(s) and monitor to verify conformity within required timeframe.
- Manage the day-to-day operations of the Program.
- Provide regular reports to the Government Compliance Officer and Chief Compliance Officer on the status of the Medicare, Medicaid or Marketplace Compliance Program.
- Develop and maintain policies and procedures to foster a culture of compliance; continually monitor and evaluate the adequacy and efficacy of policies, procedures and company adherence.
- Assess risk through a formal risk assessment process and develop and implement an annual audit plan to monitor and ensure compliance with laws and regulations. The audit plan should be refreshed quarterly to assess changes to the risk assessment.
- Create and implement educational training programs to ensure knowledgeable about the Medicare, Medicaid or Marketplace Compliance Program and all applicable statutory and regulatory requirements.
- Develop and implement methods and programs that encourage managers and employees to report Medicare, Mecaid, or Marketplace program noncompliance and suspected fraud, waste, and abuse (FWA) and other misconduct without fear of retaliation.
- Respond to reports of potential instances of FWA, including the coordination of internal investigations and the development of appropriate corrective or disciplinary actions, if necessary.
- Work with business unit or third-party vendor to determine root cause of risks and resolve through modified procedures, training, systems or disciplinary actions; coordinate and serve as a liaison during compliance audits and exams.
- Work with various governance committees, policy workgroups, other infrastructure areas and the businesses on all aspects of the Compliance Program including intitiatives, project management, reporting and monitoring.
- Coordinate summarizing the efforts and activities of Medicare, Medicaid, or Marketplace Compliance Program for the Government Compliance Officer to communicate to the internally developed Executive Compliance Committee and Audit Committee.
- Other duties as assigned or requested.
- Bachelor’s Degree in Business, Healthcare or other related area
- In lieu of a degree, equivalent experience will be accepted
- Masters Degree in Business, Healthcare, or other related area
- 5 - 7 years of experience in Health Care Field
- 3 - 5 years of experience in applicable government business compliance (Medicare, Medicaid, or Marketplace)
- Broad-based business knowledge as well as in-depth knowledge of the insurance industry, strategic compliance planning, regulatory concerns, compliance requirements, and Corporate Integrity principles
- Experience with managed care, Medicare and Federal and/or State regulations, quality improvement and compliance oversight.
- High-level of skill in leading interdepartmental and cross-functional strategy development
- Excellent oral, written, and presentation skills
- Conceptual and analytic skills are necessary in order to review and articulate corporate objectives and Federal regulations across all relevant audience
- The ability to comprehend and interpret regulatory, legislative, and contractual mandates
- Compliance and/or regulatory experience with proven ability
- Simultaneous manage multiple projects
- Manage initiatives to ensure compliance with CMS regulations
- Thorough knowledge of Medicare Advantage and Medicare Prescription Drug, healthcare trends, managed care insurance
- The utmost integrity in the discreet and confidential handling of confidential materials is necessary
- Experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met
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