The Regulatory Compliance Senior Manager oversees and conducts various compliance-related activities for the Company's Medicare Advantage (Part C) and Prescription Drug (Part D) health plan programs. The Manager's primary function is to maintain an understanding of applicable regulatory and legal requirements, policies, and procedures related to the operation of Medicare Advantage organizations, and conduct various activities to communicate, effectuate, and validate compliance with such requirements. The Manager serves as a business partner/consultant with health plan operational areas and client organizations, working with the Compliance team and various others to reduce risk and prevent, detect, and correct issues of non-compliance.Job Description:
Role and Responsibilities:
- Monitor, review, and interpret Medicare and other regulatory requirements; timely distribute regulatory guidance and other information to applicable business owners and utilize effective methods to track and document compliance with applicable guidance. Follow up with appropriate functional areas to ensure any changes required by regulatory guidance are implemented. Escalate issues and concerns. Summarize key regulatory guidance and deliver to peers, leaders, and/or governing bodies. Maintain calendar of required regulatory activities and track to ensure the Company remains current on required responses, submissions, activities, and due dates.
- Collaborate with health plan functional leadership and staff, serving as Medicare regulatory subject matter expert, to evaluate operating procedures, systems, and standards for compliance with regulatory guidance and internal policies and procedures. Identify potential or actual compliance risks or deficiencies and provide suggestions for resolution. Identify needs for operational policies and procedures and work with business owners to maintain appropriate and current documentation. Foster an open and honest risk management and compliance culture across all operations for timely reporting and escalation of regulatory risk issues.
- Develop and/or conduct staff and leadership training as appropriate to reinforce or improve understanding of regulatory requirements, especially when significant changes to guidance occurs.
- Serve as a regulatory advisor to health plan operational areas and the Compliance team; may work with regulatory authorities as needed relative to Compliance Program and health plan operations activities, including participation in regulatory site visits, meetings, and conferences.
- Oversee and participate in the preparation and dissemination of regulatory guidance summaries and detailed communications to client health plan organizations, identifying applicable business owners, actions, responsibilities, and timelines. Conduct research and work with business owners to identify responsibilities delegated by client organizations and ensure any follow-up communications are delivered.
- Collaborate with legal counsel, Compliance and Operations leaders, and others as appropriate regarding the review and response to regulatory requests for comments on new or updated guidance.
- Supervise, train, and support Compliance Analysts in their responsibilities to objectively partner with health plan operations units as Compliance subject matter experts. Analysts must understand regulatory requirements specific to various operations areas; understand operational policies, procedures, and systems; have the ability to identify, report, and manage risks or incidents; and work with business units to correct issues of potential or actual noncompliance.
- Conduct employee performance evaluations, create individual and team objectives and development plans, interview candidates, create new-hire orientation plans, manage employee relations, and perform other managerial/human resources responsibilities as needed or required.
- Oversee and participate when needed in the timely review of health plan marketing materials to verify materials are compliant with current regulatory and policy requirements. Maintain awareness of processes and procedures specific to each client organization and ensure reviews are conducted in accordance with the applicable contractual requirements of each client.
- Work with health plan first-tier, downstream, and related entities, business associates, vendors, and other contracted parties regarding various health plan regulations, operational procedures, and any compliance matters that may arise. Participate in vendor oversight meetings and activities as Medicare regulatory subject matter expert.
- Support the investigation of reports of health plan non-compliance if needed, which may include assisting the investigator or independently reviewing documents, data, and processes; conducting or participating in root cause analyses; and preparing or assisting with preparation of corrective action plans for founded incidents.
- Develop, implement, track progress, and report on regulatory compliance objectives, projects, timelines, and deliverables for the Compliance Program. Create and maintain operational dashboards, analyzing and trending data to evaluate performance in various areas. May present dashboard reports to senior leadership and/or governing bodies.
- Contribute to and participate in the Compliance Awareness, Training, and Education Program as needed to support continuous learning as well as annual mandatory compliance training requirements.
- Partner with managers of other Compliance Program functions, including Auditing and Monitoring, Special Investigations Unit, Reporting, and Compliance Program Administration, contributing expertise in these areas to help fulfill overall Program needs and responsibilities.
- Review and recommend revisions to the Health Plan Compliance Program and Compliance Policies & Procedures as appropriate to respond to changes in the Company's needs and applicable legal requirements, identified weaknesses in the Program, or identified systemic patterns of noncompliance.
- Participate as a member of various standing or ad hoc committees within the Company.
- Collaborate with supervisor, Chief Compliance Officer, General Counsel, or other subject matter experts as necessary for any issues where it is determined that the expertise of these individuals should be consulted.
- Advocate for compliance and ethics in the operation of the Company's health plan activities, delivering a clear message throughout the organization that individuals are expected and encouraged to bring any compliance concerns to the attention of appropriate authorities, and that the Company has a firm policy of non-retaliation against those who make such disclosures.
- Maintain education, awareness, and knowledge of current regulations and best practices in the health care industry and in the management of health plan operations. Cross-train team members for continuous departmental improvement and strengthening of core competencies.
- Other related duties as assigned to meet departmental and Company objectives.
Experience, Qualifications and Education:
- Bachelor's degree in health care administration, compliance, law, business, or a related field.
- Professional certification(s) that demonstrate healthcare and/or compliance expertise (CHC or CCEP preferred)
- Minimum of two years' experience in a corporate compliance program in a federally regulated environment, preferably health care, including interacting with government agencies and regulators.
- Minimum of one year general auditing/monitoring experience, with understanding of and ability to conduct monitoring activities, root cause analyses, and basic auditing/corrective action plan development
- Minimum of three years' experience supervising, coaching, and leading staff.
- Knowledge of health care and/or insurance practices and procedures, healthcare laws, regulations, and standards. Familiarity with operational, financial, quality assurance, and human resource procedures and regulations.
- Analytical and research skills; ability to interpret data, regulations and laws, conceptualize, and disseminate information in a readily understandable manner.
- Investigatory skills; ability to organize, analyze, and effectively determine risk with corresponding solutions.
- Excellent computer skills, specifically with Microsoft Word, Excel, PowerPoint, and Outlook. Knowledge of Compliance 360 and SharePoint preferred. Ability to learn, understand, and apply new technologies.
- Excellent written and verbal communication skills; presentation skills with ability to create and deliver training, informational, and other types of programs.
- Ability to effectively communicate with individuals at all levels of the organization, as well as external parties.
- Excellent negotiation, problem-solving, and conflict management skills.
- Energetic and forward thinking with high ethical standards and a professional image.
- Collaborative and team-oriented; leader; role-model; ability to develop team skills and encourage individual growth.
- Ability to plan proactively and interpret complex processes and programs. Excellent follow-up skills to keep projects and tasks on track.
- Ability to meet stringent deadlines, perform a high volume of activities, prioritize work, delegate clearly and effectively, and respond to changing demands.