Position Overview The Senior Federal and Integrated Product Compliance Specialist reports to the Director, Federal and Integrated Product Compliance and serves as a lead for overseeing and managing compliance activities for Medicare and integrated products, such as Medicaid Advantage Plus (MAP). The position plays a key role in product-specific reviews, Compliance Program Effectiveness (CPE) readiness activities, and external CMS and Department of Health audits and surveys. The position supports operational compliance with state and federal regulations, contractual requirements, and new or revised policy guidance, and is responsible for identifying compliance risks through audits and monitoring, driving corrective actions and remediation, and ensuring compliance plans, policies, and related materials remain accurate, current, and aligned with regulatory requirements through proactive review and stakeholder coordination.
- Support the development and execution of the Annual Compliance Risk Assessment and Compliance Work Plan for Medicare, and integrated products, such as MAP.
- Lead Compliance Program Effectiveness (CPE) readiness efforts, driving sustained alignment with CMS compliance program requirements, and serve as the primary compliance liaison for CPE audits and all product-related external regulatory audits, reviews, and validations, including CMS and Department of Health (DOH) surveys.
- Plan and execute complex internal auditing and monitoring activities across Medicare and Integrated lines in accordance with the Compliance Work Plan and emerging risk areas, independently identifying issues and trends.
- Prepare and deliver high-quality, timely compliance reporting for senior leadership, the Internal Compliance Committee, and the Audit and Compliance Committee of the Board.
- Lead corrective action management efforts following identification of non-compliance, including guiding business owners through root cause analysis, development of corrective action plans, and validation of remediation effectiveness.
- Lead the design, execution, and refinement of monitoring metrics used by business areas to assess ongoing adherence to Medicare and integrated product regulatory requirements.
- Ensure the investigation and analysis of compliance issues by providing regulatory interpretation, subject-matter expertise, and documentation guidance.
- Review and contribute to product-specific compliance training content, ensuring alignment with current regulatory requirements and operational realities for Medicare and integrated products.
- Collaborate with the Compliance Implementation Specialists by providing subject-matter input to support implementation of new and revised regulatory guidance, contractual requirements, and CMS and state rules
- Review and update policies and procedures to reflect Medicare and integrated product regulatory and contractual requirements, identifying gaps and recommending actionable enhancements.
- Perform other advanced compliance functions as assigned, consistent with an experienced professional capable of operating autonomously, exercising judgment in a complex regulatory environment.
Minimum Qualifications - A bachelor's degree in public health, public policy, or public administration required.
- 4 years of experience in compliance, product, or operations is required
- Experience with Medicare and integrated products is required.
- High-level of skill in leading interdepartmental and cross-functional strategy development and project management; experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met. Ability to manage simultaneously manage multiple projects.
- Experience in Microsoft Office suite products including Outlook, Excel, SharePoint, and MS Teams a plus.
- Certified Healthcare Compliance (CHC) or Certified Compliance & Ethics Professional (CCEP) certificates are preferred.
Professional Competencies - Integrity and Trust
- Customer Focus
- Functional/Technical skills
- Excellent oral, written, analytical, and critical thinking skills.
- Must have the utmost integrity in the handling of discreet and confidential materials.
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