The Director of Medicare Compliance works directly with the Vice President Medicare Compliance/National Medicare Compliance Officer to develop and maintain an effective Health Plan Regulatory Compliance Program. This position is responsible for leading the development, implementation, and ongoing maintenance of elements of an effective Compliance Program, including Regulatory and Contractual Compliance for each CCA Program; GRC system implementation; Compliance Auditing and Monitoring programs.

This position is also responsible for the oversight of all Medicare regulatory and contractual requirements related to each CCA Program; and disseminating requirements to appropriate internal staff.

The Director of Medicare Compliance is accountable to strengthen internal controls, educational requirements, reporting, and complaint mechanisms, proactive monitoring and mitigation of risk, and compliance expectations of all personnel and FDRs supporting business operations.

This position plays a strategic role in shaping the overall Compliance infrastructure at Commonwealth

Care Alliance (CCA).

Supervision Exercised:

Yes, which includes but is not limited to providing leadership, work direction, and performance feedback to subordinate staff.

• Medicare Compliance Program

  • Ensure Medicare Compliance Program Description and Policies are reviewed and updated on a regular basis
  • Develop and implement methods and programs that encourage managers, employees, and FDRs to report program noncompliance without fear of retaliation
  • Maintain and/or have access to applicable compliance reporting mechanism and closely coordinating with the Internal Audit Department and the FWA/SIU functions
  • In conjunction with the VP Medicare Compliance, participates in the development, implementation, and facilitation of strategies for all compliance related activities
  • Participate in investigations of reported compliance concerns, developing recommendations for

  appropriation corrective action

  • Oversee monitoring/auditing function for Medicare regulatory compliance operational business units
  • Oversight of CCA's Medicare Compliance Research Program
  • Work collaboratively with management, workforce, and contractors to ensure program-wide

  compliance efforts are and remain in alignment with CCA's Code of Conduct with business

  operations, and with federal, state, and local requirements

  • Provide regular reports to compliance leadership, SLT/ELT, internal Compliance Committee, Audit

  Oversight of Regulatory and Contractual Reporting

  • Ensure an accurate and complete inventory of regulatory and contractual Medicare reporting requirements is maintained
  • Work directly with Regulators to resolve any questions or discrepancies in reports as needed
  • Develop processes and workflows to promote accurate and timely reporting submissions
  • Continuously monitor the Reporting program to identify needed enhancements
  • Work directly with CCA leadership to resolve any ownership and/or data issues related to reporting
  • Oversee the development of metrics and reporting to demonstrate effectiveness of CCA's Medicare compliance program
  • Ensure metrics are reported regularly and updated as needed to demonstrate effectiveness
  • Provide mechanism for escalation when metrics begin to show issues with operational efficiency
  • Identify, prioritize and scope needed system enhancements

  Compliance Program Metrics

  • Oversee and manage processes that generate Compliance data to ensure it meets all requirements for applicable laws and regulations that govern the industry
  • Oversee the development of metrics and reporting to demonstrate effectiveness of CCA's compliance program
  • Ensure metrics are reported regularly and updated as needed to demonstrate effectiveness
  • Provide mechanism for escalation when metrics begin to show issues with operational efficiency
  • Identify, prioritize and scope needed system enhancements

  Support Overall Compliance Infrastructure

  • Work collaboratively with the VP Medicare Compliance on strategic department planning including budget development, staff resource allocation and shaping the overall Regulatory Affairs Compliance infrastructure.
  • Promote compliance in CCA's business operations with all Medicare and Medicaid contractual and regulatory requirements.
  • Develop, implement, and maintain a system to monitor and track day to day compliance activities across the organization.
  • Serve as Regulatory Affairs and Compliance liaison with key internal departments
    • Provide guidance and assistance as requested
    • Hold meetings with department leadership at agreed upon intervals
    • Attend department staff meetings and present information as requested
    • Assist in development of regulatory toolkits and instruction materials as needed to assist departments with regulatory projects and process implementation
    • Support business units in interpretation of regulations related to their applicable areas as well as provide assistance in developing appropriate tools to ensure compliance
    • Provide consultation with business owners in developing policies and procedures and/or building internal workflows to ensure internal controls of high-risk regulatory requirements are in place and working effectively
  • Project manage multiple organization-wide initiatives that occur on an annual or on an ad hoc basis.

  Working Conditions:

  • Standard office conditions

Qualifications:

• Bachelor's degree required,Master's degree in health careadministration, public administration, public health, or business administration is preferred.
• Certified Healthcare Compliance (CHC) preferred
• 7 or more years direct work experience inregulatory affairs and/or compliance required
• 7 or more years of managerial experience is required.
• Health care industry experience required.
• Project management skills or equivalentare required
• Strong written, verbal, listening and communication skills - having the ability tounderstand and communicate appropriately to the targeted audience
• Strong supervisory/managerial skills. Manage staff workload appropriately andidentify areas of improvement and areas for professional development for staff
• Strong analytical skills - having the ability to identify an issue, conduct an analysis todetermine business impact (including gap analyses), troubleshoot
• Strong project management skills - having the ability to effectively manage multiplepriorities simultaneously by maintaining established timeframes, adhering to work plans, and communicating changes effectively
• Strategic thinking and planning to continue to enhance the Compliance Program and the role of compliance within the organization: ability to initiate and develop new solutions to problems, to identify new opportunities; and have organizational perspective to see how the pieces fit and reflect that perspective in day-to-day decisions
• Ability to influence team members and owners to resolve issues in atimely manner
• Requires diplomatic and negotiation skills and understanding of needs of internal andexternal partners
• Ability to work independently
• Ability to present information clearly in meetings and to communicate with team members and senior leadership
• Requires excellent interpersonal skills in order to communicate and work with staff of all skill and experience levels
• Self-directed with proven initiation skills
• Must be able to effectively communicate with colleagues, internal customers, andvendors

  Required Language (must have):

  • English