Director, Provider & Member Configuration

§ Oversee and conduct various compliance-related activities for the Company’s Medicare Advantage (Part C) health plan program

§ Provide strategic leadership for the Corporate Compliance Program to ensure organizational compliance with CMS and applicable regulatory and accreditation requirements, incorporation of new requirements into plan operations, monitoring plan performance against requirements, related policy and procedures, and, instituting corrective action plans, as required

§ Work in collaboration with Regulatory to ensure understanding and/or advocate on various policies related to Medicare Advantage and related Medicare programs

§ Provide leadership for the Medicare Corporate Compliance Program, maintaining and implementing the corporate compliance plan, with its integrated code of conduct, and supporting policies and procedures.

§ Monitor and review regulatory and legislative requirements and changes; respond to regulatory requests, audits, and investigations, communicate and implement regulatory requirements; and, follow-up with appropriate areas to ensure required changes are effectively implemented.

Ensure staff and leadership training on the regulatory environment, programs and requirements, to include new hire training, annual training for all staff, and function specific training as appropriate.

Develop, implement, and oversee an annual compliance monitoring program, integrating with the overall corporate audit plan. Assist internal audit and monitoring program to assess compliance with applicable health plan laws and compliance program requirements, ensuring the seven elements of an effective compliance program. Oversee the risk assessment process, draft audit work plans and conduct internal audits and develop audit reports, assist business partners in interpreting audit findings, prepare and complete audit responses, and develop corrective actions.

Coordinate organizational participation in federal, state, EQRO and IRO regulatory audits and site visits.

Manage compliance with the OIG CIA including coordination of annual training, IRO reviews and annual reporting.

Create and maintain compliance related dashboards, including health plan compliance plan objectives, projects, timelines and deliverables for the Medicare Compliance Program, analyzing and trending data to evaluate performance.

Staff the Corporate Compliance Committee and support reporting to the Board of Directors as appropriate.

Identify and address areas of compliance risk for the organization with implementation of mitigation strategies.

Coordinate with the Government Contract Administration staff to support the organization in assessing and incorporating new program requirements into operations.

Ensure a comprehensive HIPAA Privacy compliance program is in place to meet federal, state and accreditation requirements.

Drive the focus and management of plan initiatives and performance monitoring to obtain success in regulatory incentive programs.

Provide management and oversight of compliance program staff, serving as a resource to maximize staff knowledge/on-going compliance expertise.

Perform any other job related instructions, as requested

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