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Job Summary

The Program Manager Medicare Compliance is responsible for assisting with all Medicare Advantage (MA) compliance activities. The position manages the operations of Compliance, including components of the administration, interpretation, and enforcement of the Compliance Program and managing the regulatory affairs, prevention, detection, and correction functions of Compliance.

Requirements

EDUCATION

Bachelor's degree required.

LICENSING/CERTIFICATION

Certification in Health Care Compliance or pursuit of certification preferred. 

EXPERIENCE

Minimum seven (7) years' government compliance experience in a healthcare insurance or CMS government program environment. OR applicable Masters in related field and Certified Healthcare Compliance designation with minimum five (5) years' experience.

Minimum three (3) years' direct Medicare Advantage compliance experience.

Minimum two (2) years' leadership experience (role, team lead, project management, etc.)

Strong understanding of CMS requirements and regulations related to Medicare Advantage and Medicare Part D operations and compliance.

Experience with CMS Program Audits. Financial audits, data validation audits, CMS reviews, and CMS’ HPMS modules required.  

Strong knowledge of CMS regulations pertaining to compliance in a managed care health plan, and the Medicare Managed Care Manual, is a must. 

Compliance experience coupled with excellent “hands-on” development, implementation, and maintenance of compliance programs, policies and procedures.

Strong understanding of the seven elements of an effective compliance program and the CMS methodology of Prevent, Detect, and Correct Knowledge of applicable legislation/regulations and responsible for departmental implementation and ongoing compliance.

ESSENTIAL SKILLS & ABILITIES

Oral & Written Communication

Collaborative

Project Management

Organizational

Ability to work with cross-functional stakeholders and external partners including state and federal regulators.

Ability to handle multiple projects at one time.

Ability to effectively present highly complex information and respond to questions from groups of managers, clients, customers, and the general public.

Ability to maintain confidentiality related to sensitive matters.  Strong ethical foundation and trustworthy character.

Skills

Responsibilities

• Continually analyzes business needs, identify potential problems, ensure effective lines of communicating business and compliance issues, and assist in remediation.
• Develops and maintains strong working relationships both internal and externally, collaborating and consulting with business and regulatory partners.
• Develops and oversees a system for uniform response, enforcement and corrective action on matters relating to MA compliance, improper or illegal actions including, where appropriate, the reporting of potential violations of laws or regulations to appropriate authorities.
• Ensures that employees are trained on ABCBS’ commitment to compliance with all applicable federal and state laws and regulations.
• Ensures timely and accurate submissions of CMS-required documents.
• Establishes and oversees readily accessible communication channels, including a compliance hotline, through which any employee can raise questions or concerns or report possible violations of the Compliance Program and without fear of retribution or retaliation.
• Executes the operational functions of the MA Compliance Program to effectively prevent, detect and corrective violations of law, regulations and the Code of Conduct by the Company’s directors, officers, and employees.
• Maintains a log of all MA compliance issues received by the compliance hotline or through any other mechanism, maintain a record of all allegations which may constitute a material violation of applicable laws or regulations, and conduct a preliminary review and, if necessary, an investigation of any credible allegation of non-compliance.
• Manages the development and participation in regular, multifaceted communication, educational, and training programs to ensure all Company directors, officers, employees, consultants, vendors and subcontractors who work on MA products are knowledgeable about and comply with the MA Compliance Program, and all federal, state and local laws and regulations.
• Oversees vendor compliance.
• Works with internal and external auditors, as necessary, to ensure effective coordination and implementation of audit requests, and ensure audit readiness.

Certifications

Certified in Healthcare Compliance (CHC) - Compliance Certification Board (CCB)

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.