Program Manager, Medicare Compliance

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

📋 Description

• Continuously evaluates business requirements, identifies potential issues, ensures effective communication regarding business and compliance matters, and aids in remediation efforts.

• Cultivates and sustains robust working relationships both internally and externally, engaging in collaboration and consultation with business and regulatory stakeholders.

• Designs and manages a system for consistent responses, enforcement, and corrective measures concerning MA compliance and any improper or illegal activities, including, when appropriate, reporting potential legal or regulatory violations to the relevant authorities.

• Guarantees that employees receive training on ABCBS’ dedication to adhering to all relevant federal and state laws and regulations.

• Ensures prompt and precise submissions of documents required by CMS.

• Establishes and supervises easily accessible communication channels, including a compliance hotline, enabling employees to raise questions or concerns or report potential violations of the Compliance Program without fear of retaliation.

• Implements the operational aspects of the MA Compliance Program to effectively prevent, detect, and correct violations of laws, regulations, and the Company's Code of Conduct by its directors, officers, and employees.

• Maintains a record of all MA compliance issues reported through the compliance hotline or other means, keeps a log of all allegations that may signify a material violation of applicable laws or regulations, and conducts preliminary reviews and, if necessary, investigations of any credible non-compliance allegations.

• Oversees the development and engagement in regular, comprehensive communication, educational, and training initiatives to ensure that all Company directors, officers, employees, consultants, vendors, and subcontractors involved with MA products are informed about and comply with the MA Compliance Program, as well as all applicable federal, state, and local laws and regulations.

• Manages vendor compliance.

• Collaborates with internal and external auditors as needed to ensure effective coordination and execution of audit requests while maintaining audit readiness.

⛳️ Requirements

• A bachelor’s degree is required.

• Certification in Health Care Compliance or the pursuit of certification is preferred.

• At least seven (7) years of government compliance experience in a healthcare insurance or CMS government program setting.

• Alternatively, a relevant Master's degree and Certified Healthcare Compliance designation with a minimum of five (5) years' experience.

• A minimum of three (3) years' direct experience in Medicare Advantage compliance.

• At least two (2) years' leadership experience, such as in a role, team lead, or project management capacity.

• A strong grasp of CMS requirements and regulations pertinent to Medicare Advantage and Medicare Part D operations and compliance.

• Experience with CMS Program Audits is necessary.

• A comprehensive understanding of CMS regulations related to compliance in a managed care health plan, including familiarity with the Medicare Managed Care Manual, is essential.

• Compliance experience combined with exceptional hands-on development, implementation, and maintenance of compliance programs, policies, and procedures.

• Strong understanding of the seven elements of an effective compliance program and the CMS methodology of Prevent, Detect, and Correct.

• Knowledge of applicable legislation/regulations and responsible for departmental implementation and ongoing compliance.

🏝️ Benefits

• Tuition reimbursement.

• Club Blue, a complimentary onsite gym to promote physical activity.

• Green Leaf Grill and Green Leaf Grill Express, onsite dining options in Little Rock that encourage healthy eating.

• Incentives for wellness education and physical fitness.