Medicare Advantage Compliance Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Monitor and interpret CMS regulations, sub-regulatory guidance, HPMS memos, and CMS transmittals.

• Assess operational impacts and ensure timely implementation of necessary changes for Medicare Advantage and Managed Medicaid plans.

• Coordinate root cause analyses (RCA) and corrective action plans (CAPs), ensuring prompt resolution and effective implementation through documented follow-up.

• Analyze monitoring data to identify trends, anomalies, or potential non-compliance and provide actionable recommendations.

• Create and maintain tracking tools, reports, and dashboards for compliance monitoring and remediation follow-up.

• Assign, track, and monitor the completion of compliance, Fraud, Waste & Abuse (FWA), and HIPAA privacy and security training.

• Conduct monthly OIG and GSA exclusion-list screening for employees and vendors; investigate and escalate positive matches.

• Support the development and maintenance of compliance policies, procedures, and related documentation.

• Maintain knowledge of federal and state regulations, including CMS Medicare Advantage and Medicaid Managed Care rules, HIPAA, and state-specific health plan requirements.

• Participate in compliance risk assessments, policy and procedure development, monitoring work plan development, Compliance Committee reporting, annual Medicare Parts C & D reporting, external audit readiness, and audit support.

• Meet regularly with the Chief Compliance Officer to establish priorities, align work efforts, and discuss issues and opportunities for improvement.

⛳️ Requirements

• 3-4 years of experience in healthcare compliance with a focus on Medicare Advantage regulatory monitoring.

• Bachelor’s Degree from an accredited university or equivalent experience.

• Strong understanding of applicable laws, regulations, and standards impacting health plans, including CMS, Medicaid, HIPAA, and OIG.

• Experience managing Root Cause Analyses (RCAs) and Corrective Action Plans (CAPs).

• Familiarity with exclusion screening processes (OIG/GSA) and vendor oversight.

• Proficient writing skills; ability to communicate effectively and succinctly, conveying information clearly and logically without ambiguity.

• Ability to analyze data and facts and draw logical conclusions.

• Sound decision-making abilities and meticulous attention to detail.

• Proven capability to perform at a high level in a fast-paced, demanding compliance environment.

• Strong, self-directed individual capable of managing complex responsibilities with consistency and precision.

• High degree of discretion in handling confidential compliance-related matters.

• Certification in Healthcare Compliance, such as CHC or CCEP.

🏝️ Benefits

• 100% remote work culture with the opportunity to work within the U.S.

• Comprehensive health, dental, and vision coverage for you and your family.

• 5 weeks of paid vacation and holiday time off.

• Traditional and ROTH 401k with company match.

• Company-paid life insurance, AD&D, and long-term disability coverage.

• Tuition reimbursement.

• Parental leave.

• Employee assistance with resources for mental health, financial wellness, and more.