Senior Manager, Compliance; Health Plan​/MCO

Job Summary:

The Senior Manager, Compliance provides compliance oversight, organizational leadership related to compliance, ensures the department proactively collaborates with partners, provides insights from analyses being conducted and leads a team that develops and maintains comprehensive State and Federal Regulatory Guidebooks, job aids, and other tools and resources needed to support wide-spread compliance in delegated and non-delegated Marketplace (Qualified Health Plan), Medicare and Medicaid services as applicable to the Senior Manager’s specific product oversight.

Strong health plan/MCO compliance and AI experience preferred.

Essential Functions:

• Serve as a compliance leader in the Marketplace, Medicare and Medicaid arena as applicable
• Manage the Federal and State regulator relationships including but not limited to the Center for Consumer Information and Insurance Oversight (CCIIO) and Centers for Medicare & Medicaid Services (CMS) Federal account managers, Department of Insurance (DOI) State regulators and State Medicaid regulators (collectively “regulators”) and oversee the development, execution, and follow-up for regulator meeting agendas
• Oversee all Marketplace, Medicare and Medicaid compliance activities performed and tracked by compliance staff including, but not limited to, internal business owner and external regulator inquiry management, State complaint management, regulatory distribution management, and compliance workplan execution
• Lead and organize Marketplace, Medicare and Medicaid Compliance Committees and work groups as applicable, representing both State and Federal updates across all markets
• Oversee Marketplace, Medicare and Medicaid policies and procedures (P&P) and standard operating procedures (SOP) to ensure compliance with Federal and State regulatory, statutory, corporate, and contractual standards and obligations
• Remain current in Federal/State laws and regulations regarding Marketplace, Medicare and Medicaid requirements as well as general compliance and delegation oversight best practices and industry standards
• Provide feedback to Compliance leadership concerning key risks in Marketplace, Medicare and Medicaid so that Compliance leadership may complete the annual compliance risk assessment
• Assist with the execution of the compliance work plan
• Respond to compliance incidents and ensure appropriate reporting and communication with business leaders and compliance team members
• Provide feedback and recommendations for ongoing monitoring or improvement to the Compliance Corrective Action Team regarding corrective action plans
• Oversee and ensure that all Marketplace, Medicare and Medicaid compliance activity tracking is developed, maintained and reported to internal and external stakeholders
• Assist with regulatory audits and support audit readiness activity
• Assist with oversight of data validation of all internal and external compliance and regulatory reporting
• Act as a resource for internal departments to assist with external-entity related escalated issues
• Identify compliance knowledge gaps and collaborates with applicable business teams to develop training programs to address the gaps
• Provide compliance training for all internal and external stakeholders to ensure compliance program effectiveness
• Cultivate effective relationships, collaborate with, and provide Marketplace, Medicare and Medicaid compliance expertise including both State and Federal requirements to Market leadership, and other Corporate leadership and business departments to ensure effective compliance program management
• Establish and maintain positive working relationships with State and Federal regulators ensuring to build goodwill and trust for Care Source as an entity
• Provide subject matter expertise…