Director, Compliance

**Job Description

_Who we are:

**_ At UST HealthProof, you will join a fast-paced, growing company in our mission to reshape the future of health insurance by significantly reducing administrative costs and building better healthcare experiences for our health plan customers and their members. By creating a modern, cloud-based, Best-In-Class core administration ecosystem,we have made healthcare more affordable and helped our health plans operate more efficiently. Through member and provider touchpoints with less friction, we have created a real impact for members.

UST HealthProof is run by leaders with strong health plans and technology backgrounds a startup mindset and an environment of support where individual growth is nurtured. You will be supporting our proven core admin solutions and business process-as-a-service (BPaaS) operations to provide transparency, improve operational efficiency, break down operational barriers to scale, and drive strategic growth.

Visit us at UST.com **

You Are**

As a Director of Compliance, under the direction of the Chief Compliance Officer, oversee and maintain Company compliance with contractual and regulatory obligations and all state and federal requirements related to health insurance and managed care. The Director of Compliance will build and manage strategic partnerships with internal business units and external clients, toward a common goal of compliance excellence. The Director of Compliance will support the Chief Compliance Officer with implementing and leading an effective Compliance Program, ensuring ongoing oversight of compliance-related activities associated with Advantasure’s product offerings. Furthermore, the Director of Compliance will ensure the company maintains positive relationships with both internal and external stakeholders. **

The Opportunity**

This position serves as primary support to the Chief Compliance Officer for regulatory compliance. This position will primarily oversee functions including, but not limited to:

• Lead the regulatory and sub-regulatory research and policy initiatives, including monitoring changes to CMS regulations and guidance, providing comprehensive summaries and impact analysis to business stakeholders on those changes, and ensuring implementation of any necessary process changes.
• Perform complex regulatory analysis and provide interpretation to internal/ external stakeholders as necessary.
• Establish and maintain a baseline risk assessment, factoring in major compliance, privacy, and FWA risk areas.
• Implement and maintain an ongoing risk mitigation program intended to address actual or suspected risks in real time.
• Serve as a liaison with clients and regulatory agencies for the day-to-day management of contractual and regulatory compliance issues that impact operations.
• Lead and/or support various enterprise strategic initiatives.
• Support the implementation/ ongoing oversight of the organization’s Compliance Program.
• Implement and oversee the FDR Compliance Program, including offshore subcontracting oversight.
• Attend executive management meetings to represent the Compliance department.
• Lead compliance investigations and disclosures to executive leadership/ clients, as necessary.
• Perform FDR determinations and administer the Delegated Vendor Risk Assessment.
• Function as a liaison with Medicare Advantage/ Part D Sponsor clients and facilitating governance calls with the clients.
• Coordinate with Operational Compliance and Audit and other stakeholders to ensure operational implementation of new/ revised processes is done so in alignment with regulatory requirements
• Provide support as needed to Operational Compliance and Audit to carry out the Compliance auditing and monitoring efforts.

Responsibilities

• Monitor changes to CMS regulations and guidance, provide comprehensive summaries to business stakeholders on those changes, and update policies, procedures, and training materials as needed.
• Conduct an extensive and thorough analysis of regulatory guidance from various sources such as Medicare Managed Care Manuals, Prescription Drug Benefit Manuals, HPMS memorandums, CMS Transmittals, Federal Register publications, etc.
• Provide regulatory interpretation support to functional areas throughout the organization, including but not limited to, Operational Compliance, Pharmacy, Appeals and Grievances, Utilization Management, Finance, Quality, Risk Adjustment, Enrollment, Premium Billing, Claims, Customer Service, Vendor Management, Client Account Management, Human Resources, and Legal.
• Manage a team of compliance professionals.
• Develop and maintain a baseline risk assessment, intended to help drive the Compliance auditing and monitoring strategy.
• Create and implement tools (surveys, tracking logs, dashboards, etc.).
• Establish and manage an ongoing catalog of risks (regulatory, sub-regulatory, compliance, etc.), prioritization mechanisms, and a means of handling risks in collaboration with other relevant departments, as needed.
• Oversee the regulatory and sub-regulatory guidance distribution, tracking, implementation, and reporting process. This includes, but is not limited to: HPMS Memorandums, CMS Transmittals, Proposed Rules, Final Rules, Medicare Managed Care Manual updates, Prescription Drug Benefit Manual updates, Rate Announcements, etc.
• Lead the Regulatory Policy Committee, ensuring stakeholders are aware of recent regulatory changes and prepared to comply with new or changing requirements.
• Support the administration of the organization’s Compliance/FWA/Privacy training program (new hire and annual).
• Maintain accurate and comprehensive documentation of compliance activities to meet the requirements of clients and regulatory agencies.
• Develop policies, programs, and compliance resource materials that encourage employees and downstream entities to report actual or potential non-compliance, FWA, privacy violations, and other improprieties without fear of retaliation.
• Serve as a business partner/consultant with stakeholders and assist in maintaining an understanding of and compliance with regulatory requirements, as well as the organization’s internal policies and procedures.
• Oversee policies and procedures and ensure appropriate and timely updates are completed, submitted, and properly stored for retrieval.
• Maintain a P&P repository for the organization’s compliance and operational P&Ps, as well as ensure stakeholders review and update P&Ps annually.
• Support operational areas by reviewing their P&Ps to ensure processes align with regulatory requirements.
• Manage the organization’s Compliance intranet site, ensuring content is accurate and current
• Coordinate with Operational Compliance and internal stakeholders to ensure the organization has established operational policies and procedures that align with established regulatory requirements.
• Complete downstream entity determinations and respond to requests from clients for all FDR Compliance Questionnaires, FDR Surveys, Offshore Subcontractor forms, etc.
• Function as the liaison with Medicare Advantage/ Part D Sponsor clients, reporting out on compliance/FWA/privacy-related concerns, risks, processes, performance, etc.
• Administer and oversee the internal and delegated vendor compliance oversight program.
• Facilitate Compliance Governance calls with clients.
• Oversee and monitor the implementation of the Compliance Program with respect to functional responsibilities.
• Coordinate with internal stakeholders to ensure OIG/SAM Exclusions screenings are being performed before hiring/contracting of any new employee, temporary employee, volunteer, consultant, governing body member, or delegated vendor, and monthly thereafter.
• Proactively identify process gaps, weaknesses, deficiencies, or business productivity/efficiency opportunities.
• Support strategic positioning of Advantasure concerning regulatory/ operational compliance and participate in strategic planning initiatives.
• Report regularly to the Chief Compliance Officer, the Compliance Committee, Executive Leadership, and other governance meetings/ committees (as necessary) on the progress of implementation and operation of the Compliance Program, including but not limited to, new/ revised regulations that will impact the organization, risks, Compliance/FWA/Privacy training related concerns, FDR Compliance Program related concerns, and other issues deemed appropriate for executive leadership attention.
• Coordinate with senior management, as well as internal/ external stakeholders, to address issues of potential/ actual non-compliance, FWA, privacy violations, or areas of risk.
• Coordinate interactions with internal stakeholders, downstream entities, clients, and regulatory agencies, including responding to and documenting responses to any requests assigned.
• Periodically (no less than annually) revise the Compliance Program and Compliance P&Ps considering changes in the organization, as well as statutes, rules, regulations, and requirements impacting Medicare Advantage and Medicare Part D.
• Develop, coordinate, and participate in a multifaceted educational and training program that focuses on the elements of the Compliance Program and seeks to ensure that all appropriate employees and management know and comply with pertinent federal health care compliance program requirements.
• Closely collaborate with Operational Compliance and Audit to ensure identified issues are tracked as risks until mitigation is complete.
• Serve as a business partner/consultant with external clients, as well as the organization’s operational areas, and assist in maintaining an understanding of and compliance with regulatory requirements and the organization’s internal policies and procedures.
• Coordinate personnel issues with the organization’s Human Resources to ensure disciplinary standards are enforced consistently for compliance violations.
• Investigate, in conjunction with counsel as appropriate, and act on matters related to compliance/ FWA/privacy, including the flexibility to design and coordinate internal investigations (e.g., responding to reports of problems or suspected violations) and any resulting corrective actions (e.g., making necessary improvements to the organization’s policies and procedures, taking appropriate disciplinary action, etc.)
• Oversee the compliance processes related to providing day-to-day assistance to internal business units/ external clients regarding regulatory compliance, including requests for information and clarification.
• Provide support to Operational Compliance and Audit as needed to effectively carry out the organization’s monitoring and auditing strategies.
• Maintain and foster a collaborative relationship with internal and external customers.
• Ensure that all activities stay on track and coordinate among all business units for deliverables to ensure ongoing compliance.
• Review conflict of interest forms for new and existing employees. Identify areas where potential conflicts of interest exist and work with the Compliance leadership to address such conflicts.
• Work with other members of the Compliance Leadership team to coordinate tasks, functions, and responsibilities for the management of the Department, at the direction of the Chief Compliance Officer.
• Continue the momentum of the Compliance Program and the accomplishment of its objectives long after the initial years of implementation.

_This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

_ What You Need

Bachelor’s degree in Healthcare Administration, Public Health, Business Administration, Population Health, Health Informatics, or a related field. A Master’s degree in a related field is preferred. Compliance professional certifications are preferred but not required.

• 10 or more years’ experience in a Medicare Advantage/ Medicare Part D environment, including experience in the areas of Medicare operations and compliance oversight.
• Prior experience managing staff is required.
• Preference is given to applicants whose experience includes a combination of Medicare Compliance, Medicare Product, and Medicare Part C and D Operations (e.g., enrollment, marketing communications, premium billing, appeals and grievances, claims, utilization management, quality, customer service, STARs, risk adjustment, etc.).

_The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.

_ Bonus Points If

You have a JD degree

_Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by local law, UST provides a reasonable range of compensation for roles that may be hired in California, Colorado, New York City, or Washington as set forth below.

_ Role Location: Remote

Compensation Range: $128,000 - 168,000 **

What We Believe

**_We’re proud to embrace the same values that have shaped UST since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone, to champion diversity and inclusion, and to place people at the center of everything we do.

_ **Humility

**_We will listen, learn, be empathetic, and help selflessly in our interactions with everyone.

_ **Humanity

**_Through business, we will better the lives of those less fortunate than ourselves.

_ **Integrity

**_We honor our commitments and act with responsibility in all our relationships.

_ _**Equal Employment Opportunity Statement

**_ _UST is an Equal Opportunity Employer.

_ _All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

_ UST reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.