Mgr, Government Compliance

Job ID: J124558
Company: Gateway Health Plan
Location: Home, AR, United States
Facility: Work From Home
Full/Part Time: Full time
Job Type: Regular
Posted at: Jun 11, 2018

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Description

JOB SUMMARY

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.

ESSENTIAL RESPONSIBILITIES

  • 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.


EDUCATION

Required

  • Bachelor’s Degree in Business, Healthcare or other related area

Substitutions

  • In lieu of a degree, equivalent experience will be accepted

Preferred

  • Masters Degree in Business, Healthcare, or other related area

EXPERIENCE

Required

  • 5 - 7 years of experience in Health Care Field
  • 3 - 5 years of experience in applicable government business compliance (Medicare, Medicaid, or Marketplace)

Preferred

  • None

LICENSES OR CERTIFICATIONS

Required

  • None

Preferred

  • None

SKILLS

  • 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

SCOPE OF RESPONSIBILITY 

Does this role supervise/manage other employees?

Yes 

WORK ENVIRONMENT

Is Travel Required?

Yes 

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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