Resp & Qualifications

PURPOSE:
Directly accountable for establishing, managing, and monitoring compliance processes for government programs, with a focus on Complaint Tracking Module (CTM) process management, vendor compliance & oversight, and operational compliance. Works with leadership, business owners, Corporate Compliance, Legal, Mandates, and delegated entities to ensure Medicare complaints, vendor activities, policies, procedures, workflows, and monitoring activities remain aligned with CMS requirements, Federal and State regulations, contractual obligations, and the Corporate Compliance framework. Identifies and mitigates regulatory risk, supports audit readiness, drives systemic improvements, and promotes timely, accurate, and compliant outcomes that improve the member experience.

ESSENTIAL FUNCTIONS:

• Leads end-to-end CTM process management to support timely complaint assignment, resolution, documentation, trend identification, and escalation of regulatory risk. Partners with operational teams to strengthen complaint outcomes, reduce repeat issues, improve process controls, and ensure CTM activities are consistently executed and monitored in accordance with CMS expectations and internal compliance standards.
• Oversees vendor management compliance for First Tier, Downstream, and related entities and delegated entities supporting Medicaid programs, including contractual and regulatory performance monitoring, issue escalation, corrective action tracking, and communication of compliance expectations. Works with vendors, delegated entities, and internal business owners to promote timely, accurate, and compliant performance.
• Provides interpretation of regulations, regulatory guidance, and CMS expectations related to CTM, complaint handling, vendor oversight, and operational compliance. Partners with business areas, Legal, Mandates, Corporate Compliance, and delegated entities to ensure policies, procedures, SOPs, workflows, systems, and monitoring activities remain current and compliant.
• Develops and manages risk-based monitoring, auditing, and control activities to test compliance with CTM, vendor, and operational requirements. Reviews findings with stakeholders, supports response to internal and external audits, identifies root causes, and works with business owners to implement corrective actions and sustained process improvements.
• Prepares, analyzes, and presents CTM, vendor compliance, audit, and risk reports to leadership, compliance committees, and operational stakeholders. Identifies trends, systemic issues, and emerging risks and recommends actions to improve compliance performance, operational efficiency, and member experience.
• Leads associate performance, training, and development activities to support effective CTM process management, vendor oversight, audit readiness, and regulatory compliance. Creates and discusses performance plans and reviews, identifies development needs, and ensures staff adhere to policies, procedures, and established compliance processes.

SUPERVISORY RESPONSIBILITY:
This position manages people.

QUALIFICATIONS:

Education Level: Bachelor's Degree in Healthcare Compliance, Risk Management, Business Administration or 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 experience in health insurance industry, managed care and government programs, health insurance compliance programs, CTM or complaint operations, vendor & delegated entity compliance and oversight, or related fields.1 year supervisory experience or demonstrated progressive leadership experience.

Preferred Qualifications

• Experience with CMS Medicare Advantage requirements, CTM process management, complaint handling, First Tier, Downstream, and related entity oversight, vendor management compliance, monitoring, auditing, and corrective action management.

Knowledge, Skills and Abilities (KSAs)

• Incumbent must display leadership qualities, functional expertise, and business perspective.
• Excellent interpersonal skills with ability to build consensus and agreement and bring resolution to contentious issues and entrenched interests.
• Ability to research complex issues, interpret CMS Medicare Advantage regulations and regulatory guidance, apply sound judgment to CTM process management, complaint handling, vendor and delegated entity compliance and oversight, and operational compliance matters.
• Demonstrated ability to lead problem-solving discussions.
• Strong organizational, coordination, reporting, and interpersonal skills for facilitating compliance audits, CTM oversight, vendor management compliance, and cross-functional issue resolution.

Salary Range: $113,760 - $211,167

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).

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.

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