Resp & Qualifications PURPOSE: This role manages vendor and vendor compliance programs, including program integrity for the Government Programs division. Ensures plan is in compliance with government contract and regulations. Conducts risk assessments, internal and external audits and investigations. Reviews the vendor compliance program and program integrity program for CMS, state regulatory bodies and delegated vendors.
ESSENTIAL FUNCTIONS:- Ensures compliance with policies and procedures and governmental/accreditation regulations for Medicaid and Medicare Advantage Vendors. Assist with conducting investigations of compliance violations. Responsible for managing the day to day governance process around contracting and reporting on vendor performance metrics and issue resolution.
- Assist with the development of compliance policies impacting vendors for review and approval by leadership and ensure regular policy review and consistency with contractual and regulatory requirements as well as corporate standards for Medicaid and Medicare Advantage vendors. Significantly involved in the Vendor Management Committee process including meeting elements as well as identification and escalation of critical vendor issues.
- Ensures timely completion of risk assessments and related activities for Medicaid and Medicare Advantage vendors as well as identifying potential areas of compliance. privacy vulnerability and risks. Recommends and supports the drafting of policies/procedures for the resolution of compliance/privacy, legal, and information security issues and escalates as appropriate.
- Works with business owners, Legal, TPMR, Information Security and Compliance to ensure that compliance/privacy guidance and education programs for vendors as appropriate have been developed. Support participation in these trainings as appropriate.
SUPERVISORY RESPONSIBILITY:This position has no direct reports, however, may informally lead teams in a matrix environment.
QUALIFICATIONS:Education Level: Bachelor's Degree in Business Administration or health related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 5 years healthcare experience, including progressively responsible experience in compliance, program integrity, or business management.
Knowledge, Skills and Abilities (KSAs)- Knowledge of healthcare compliance and privacy regulations and laws, Medicaid managed care, CMS billing rules, and OIG projects.
- Strong knowledge of all standard coding sets under HIPAA.
- Written and oral communication skills to effectively convey complex and detailed concepts to a diverse audience, including senior level stakeholders.
- Ability to work independently and make recommendations and decisions autonomously.
Salary Range: $72,576 - $144,144
Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department Medicare Compliance Office
Where To Apply Please visit our website to apply: www.carefirst.com/careers
PHYSICAL DEMANDS:The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US Must be eligible to work in the U.S. without Sponsorship.
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