This position establishes control points and adherence to all CMS and State Division of Insurance regulations while optimizing Medicare Programs' professional relationships with CMS Central Office, as well as with each applicable regional office. This position reports to the Chief Compliance Officer. The Medicare business generates several billion dollars in revenue annually and help provide valuable medical coverage to millions of Medicare members.
Travel up to ~25%
- Implement the Medicare Compliance Program. The Medicare Compliance Officer is accountable for defining the Medicare Compliance Program structure, educational requirements, reporting, and complaint mechanisms, proactive monitoring and mitigation of risk, response and correction procedures, and compliance expectations of all personnel and FDRs supporting our Medicare Programs business (including Medicare Advantage, Prescription Drug Program, Medicare-Medicaid Plans and Medicare Supplement).
- Ensure Medicare compliance reports are provided regularly (at least quarterly) to the board or sub-committee of the Board (i.e., Audit Committee), divisional President overseeing Medicare, and the Medicare Compliance Committee. Reports should include the status of our Medicare compliance program implementation/effectiveness, the identification and resolution of suspected, detected or reported instances of noncompliance, and our compliance oversight and audit activities; the Medicare Compliance Officer shall have express authority to provide unfiltered reports to the Board, sub-committee of the Board (i.e., Audit Committee), Chief Compliance Officer and/or senior leadership.
- Be accountable for managing and coordinating the company's interactions with CMS. The Medicare Compliance Officer is also responsible for responding to and documenting responses to CMS inquiries
- Be aware of daily business activity by interacting with the operational units and applicable FDRs
- Create and coordinate, by appropriate delegation if desired, educational training programs to ensure that applicable governing body, managers, employees, FDRs, and other individuals working/supporting Medicare program are knowledgeable about the compliance program, its written Standards of Conduct, compliance policies and procedures, and all applicable statutory and regulatory requirements
- Develop and implement methods and programs that encourage managers, employees, and FDRs to report Medicare program noncompliance and potential FWA without fear of retaliation
- Maintain and/or have access to applicable compliance reporting mechanism and closely coordinating with the Internal Audit Department and the SIU
- Support and ensure that appropriate support and actions are provided to reports of potential FWA, department and the development of appropriate corrective or disciplinary actions, if necessary. To that end, the Medicare Compliance Officer should have the flexibility to design and coordinate internal investigations.
- Ensure the DHHS OIG and Government Services Administration ("GSA") exclusion lists have been checked with respect to all employees, governing body members, and FDRs monthly and coordinating any resulting personnel issues with the sponsor's Human Resources, Security, Legal or other departments as appropriate
- Ensure the appropriate documentation is maintained for each report of potential noncompliance or potential FWA received, through any reporting source/method (e.g., hotline, mail, or in-person)
- Oversee the development and monitoring of the implementation of corrective action plans
- Coordinate potential fraud investigations/referrals with the SIU, where applicable, and the appropriate NBI MEDIC. This includes facilitating any documentation or procedural requests that the NBI MEDIC makes.
- Interview or delegate the responsibility to interview potential employees, FDRs and other relevant individuals regarding compliance issues
- Review company contracts and other documents pertinent to the Medicare program
- Review or delegate the responsibility to review the submission of data to
CMS to ensure that it is accurate and in compliance with CMSreporting requirements;
- Conduct and/or direct audits of any area or function involved with the Medicare Programs and
- Recommend policy, procedure, and process changes
- Bachelor's degree in a related field (Master's preferred)
- Minimum of 10-15+ years of experience in large, corporate healthcare
- Demonstrated experience managing an enterprise-wide relationship with CMS
- Minimum of 8 years of experience managing a compliance or governance operation in a Medicare environment
- Demonstrated successful leadership skills in program management, program execution, and people management
- Strong analytic skill set to identify and prioritize strategies and initiatives for growth
- Ability to plan, organize, administer, and coordinate a variety of large and complex services, projects, and programs
- Successful leadership and management experience building effective teams, managing cross functional teams, and continuous improvement/staff development programs
- Demonstrated superior oral/written interpersonal communication, persuasion, and negotiation skills
- Strategic thinking and demonstrated organizational leadership capabilities required
- Innovation and creativity, teamwork and communications
- Ability to successfully interface at all levels with the customer, industry, and corporate entities
*Position located in one of our nationwide offices, with expected nationwide travel.
Skills and Certifications [note: bold skills and certification are required]
Medicare Compliance experience
10-15+ years of experience in large, corporate healthcare Compliance
Generous Base Salary
Relocation Assistance Available
Commission Compensation - No
Bonus Eligible - Yes
Overtime Eligible - No
Interview Travel Reimbursed - No
10+ to 15 years experience
Seniority Level - Executive
Management Experience Required - No
Minimum Education - Bachelor's Degree
Willingness to Travel - Occasionally
Candidate must have at least 10 years of progressive Medicare Compliance leadership experience. This position maybe located in one of our nationwide offices, will consider a remote work opportunity.