Job DescriptionYour Role The Medicare Compliance team is responsible for providing oversight of Blue Shield's Medicare Advantage and Part D plan operations to help ensure compliance with CMS regulations, contractual requirements, and internal policies. The Government Programs Compliance Specialist, Senior will report to the Senior Manager, Government Programs - Medicare Compliance. In this role, you will help support the effectiveness of the Medicare Compliance Program through risk-based monitoring, audits, and compliance activities that include evaluating the accuracy, completeness and integrity of plan materials, identifying compliance risks, and partnering with business teams to promote regulatory compliance and corrective action.
ResponsibilitiesYour Work In this role, you will:
- Perform regulatory compliance reviews of Medicare Advantage and Part D plan member and marketing materials and (as required) submit materials to the Centers for Medicare and Medicaid Services (CMS) and the Department of Health Care Services (DHCS).
- Document final compliance solutions, identified risks, and mitigation plans in a controlled document.
- Monitor implementation of corrective action plans to ensure remediation activities are on track, risks are identified, and mitigation plans are developed; escalate issues to department management as appropriate.
- Summarize and distribute low to complex federal and state updates to impacted business areas.
- Provide day-to-day support to business areas that support Blue Shield's Medicare Advantage and Part D plans on low to moderately complex inquiries.
- Manage and maintain Medicare Compliance department activities e.g. development and maintenance of the department audit calendar, CMS, DMHC and DHCS audit calendar, department mailboxes, intranet website, policies and procedures, and other items as needed.
- Support calibration of risk and controls with business units supporting the Medicare line of business.
- Develop, prepare, and present analyses, reports, and recommendations to department management and other stakeholders of federal and state requirements
- Participate in multiple projects or initiatives within and outside of the department.
- Other duties as assigned.
QualificationsYour Knowledge and Experience - Requires a bachelor's degree or equivalent experience
- Requires a minimum of 5 years of relevant experience, inclusive of conducting compliance reviews of Medicare Advantage and Part D plan marketing and member communication materials
- Requires a deep knowledge of the Centers for Medicare & Medicaid Services' (CMS) compliance requirements for Medicare Advantage and Part D plan member and marketing materials, as well as the Department of Health Care Services' (DHCS) compliance requirements for exclusively aligned enrollment dual special needs plan member and marketing materials.
- Requires excellent organizational skills.
- Requires strong independent judgment, problem solving, critical and analytical skills, including an exceptional "moral compass" and work ethic.
- Requires ability to work collaboratively in a team, perform duties with minimal supervision, multi-task, and to deliver a quality product in a highly regulated, demanding, and constantly changing corporate environment.
- Requires proficiency in Microsoft Office suite programs (Word, Access, Excel, PowerPoint and Outlook), SharePoint, and the Health Plan Management System (HPMS).
- Project management or similar experience is preferred
- Professional certification (CHC - Certification in Healthcare Compliance) is preferred
HybridThis role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.
Physical Requirements:Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
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