Responsibilities include but are not limited to:

Act as liaison with third party compliance help line vendor; investigate potential compliance issues. Develop internal training programs to ensure compliance with regulatory requirements.

Support Medicare Compliance Officer by: maintaining current CMS policies; ensure various HHS contract requirements met, including the training/tracking of all new and current applicable employees and FEP BOM members; monitoring, investigation, and resolution of any member ethics complaints/allegations; completing all required internal/external reporting requirements; ensure monthly screening of employees, FEP BOM members, and applicable FDRs is completed and discrepancies resolved.

• Gather relevant data and Key Performance Indicators for compliance reports and dashboards, and prepare reports based on established reporting metrics for the group.
• Develop and update Standard Operating Policies and Procedures (SOP) for review processes and compliance. Educate stakeholders on these SOPs.
• Conduct risk assessments and identify potential non-compliance vulnerabilities and make practical business recommendations to correct non-compliance or improve insufficient processes.

Required Education, Certifications and Experience

• Bachelors Degree

• Requires a minimum of five (5) years of relevant compliance experience in a healthcare or managed care environment.

• Requires a minimum of three (3) years experience in the interpretation and application of federal and state regulations, policies and procedures, and ethical principles related to healthcare compliance.

• Knowledge of the sources of legal and regulatory requirements relevant to state and federal requirements.

• Knowledge of the Federal and State regulatory environment in the health insurance industry, with emphasis on CMS Medicare/Part D federal mandates,

• Understanding of best practice internal ethics and compliance programs.

• Excellent at organizing, managing, and handling competing projects with a proven ability to meet tight deadlines in a fast-paced environment.

• Skilled at managing a high volume of work with changing priorities and frequent interruptions while maintaining the ability to work cooperatively with a positive attitude.

• Written and oral communication.

• Facilitation, active listening, and presentation skills.

• Critical thinking skills and the ability to apply an analytical approach to regulatory research and issue remediation.

• Persuasion/negotiation and interpersonal relationship skills and the ability to effectively interact and collaborate with individuals at all levels within the organization.

• Problem solving acumen. Ability to identify potential noncompliance issues, obtain information to clarify and describe issue, exercise sound decision-making, resolve problems using appropriate risk treatment, and leverage appropriate escalation pathways.

• High degree of discretion in dealing with the confidentiality of all compliance-related issues.

Preferred Education, Certifications and Experience

• Compliance/legal, business operations preferred.

• Certified Compliance & Ethics Professional Certification (CCEP) - Compliance Certification Board.

• Certified in Healthcare Compliance (CHC) - Compliance Certification Board.

• Leadership Professional in Ethics & Compliance (LPEC) - Ethics and Compliance Institute.

People Management No

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