[Remote] Program Manager, Medicare Compliance

Note: The job is a remote job and is open to candidates in USA. Arkansas Blue Cross and Blue Shield is seeking a Program Manager for Medicare Compliance. This role is responsible for managing compliance activities related to Medicare Advantage, including enforcement of the Compliance Program and regulatory affairs.

Responsibilities

• Continually analyzes business needs, identify potential problems, ensure effective lines of communicating business and compliance issues, and assist in remediation
• Develops and maintains strong working relationships both internal and externally, collaborating and consulting with business and regulatory partners
• Develops and oversees a system for uniform response, enforcement and corrective action on matters relating to MA compliance, improper or illegal actions including, where appropriate, the reporting of potential violations of laws or regulations to appropriate authorities
• Ensures that employees are trained on ABCBS’ commitment to compliance with all applicable federal and state laws and regulations
• Ensures timely and accurate submissions of CMS-required documents
• Establishes and oversees readily accessible communication channels, including a compliance hotline, through which any employee can raise questions or concerns or report possible violations of the Compliance Program and without fear of retribution or retaliation
• Executes the operational functions of the MA Compliance Program to effectively prevent, detect and corrective violations of law, regulations and the Code of Conduct by the Company’s directors, officers, and employees
• Maintains a log of all MA compliance issues received by the compliance hotline or through any other mechanism, maintain a record of all allegations which may constitute a material violation of applicable laws or regulations, and conduct a preliminary review and, if necessary, an investigation of any credible allegation of non-compliance
• Manages the development and participation in regular, multifaceted communication, educational, and training programs to ensure all Company directors, officers, employees, consultants, vendors and subcontractors who work on MA products are knowledgeable about and comply with the MA Compliance Program, and all federal, state and local laws and regulations
• Oversees vendor compliance
• Works with internal and external auditors, as necessary, to ensure effective coordination and implementation of audit requests, and ensure audit readiness

Skills

• Bachelor's degree required
• Minimum seven (7) years' government compliance experience in a healthcare insurance or CMS government program environment. OR applicable Masters in related field and Certified Healthcare Compliance designation with minimum five (5) years' experience
• Minimum three (3) years' direct Medicare Advantage compliance experience
• Minimum two (2) years' leadership experience (role, team lead, project management, etc.)
• Strong understanding of CMS requirements and regulations related to Medicare Advantage and Medicare Part D operations and compliance
• Experience with CMS Program Audits. Financial audits, data validation audits, CMS reviews, and CMS' HPMS modules required
• Strong knowledge of CMS regulations pertaining to compliance in a managed care health plan, and the Medicare Managed Care Manual, is a must
• Compliance experience coupled with excellent “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
• Oral & Written Communication
• Collaborative
• Project Management
• Organizational
• Ability to work with cross-functional stakeholders and external partners including state and federal regulators
• Ability to handle multiple projects at one time
• Ability to effectively present highly complex information and respond to questions from groups of managers, clients, customers, and the general public
• Ability to maintain confidentiality related to sensitive matters. Strong ethical foundation and trustworthy character
• Certification in Health Care Compliance or pursuit of certification preferred
• Certified in Healthcare Compliance (CHC) - Compliance Certification Board (CCB)

Company Overview