Resp & Qualifications

PURPOSE: 
This role is accountable for directing all aspects related to the monitoring of performance under the Medicaid contract and regulatory requirements and the overall state of compliance for Medicaid and Medicaid products. Reporting to the CEO, Plan Board of Directors, and Corporate Compliance Officer, the incumbent works closely with operational teams, Corporate Compliance, Mandates and Legal departments to resolve complex issues with inter-related legal and Medicaid compliance aspects. 

ESSENTIAL FUNCTIONS:

• Direct accountability for establishing an effective compliance program based on the seven core elements of compliance. Directs the activities related to the design, development, implementation and maintenance of compliance programs across all major functional areas and vendors for Medicaid within the division. Ensures internal departments understand and implement CMS and applicable state rules, policies and regulations. Responsible for risk assessment activities for internal departments.
• Collaborates with Corporate Compliance to support all Medicaid audits, reviews and examinations conducted by internal audit staff.  Directs and oversees internal Medicaid risk assessments, to ensure that appropriate staff are fully aware of objectives and that they can produce and maintain suitable records, reports, and files which adequately document planning, execution, and reporting for all relevant activities pertaining to the regulations, including documentation and storage of policies and procedures.  Develops and implements internal compliance monitoring procedures.  Ensures conclusions, findings and recommendations for improvement or corrective action are appropriately presented to management staff for review, and verify that all findings are accurate, complete and objective.
• Maintains a database of contractual requirements and status of compliance that is auditable and trackable.  Works with leadership to ensures non-compliant activities are corrected and all compliance related changes are tracked. Monitors, assesses and reports significant matters to senior management. Point of contact for Corporate Compliance, Legal and Mandates teams to manage compliance of operational teams with the division.
• Directs a staff of training professionals in the design, development, presentation and evaluation of effective, appropriate and progressive compliance training programs in collaboration with Corporate Compliance Office and Legal. Participates in and develops training and education regarding Medicaid Compliance throughout the business unit including the development of electronic learning devices, if applicable, in concert with, if applicable, corporate audit, HRD and the Corporate Compliance Office.  Ensures that all Medicare and/or Medicaid requirements for training are met by internal departments and first tier, downstream and related entities.
• Directs the activities resulting in uniform, compliant methods and practices for executing daily activities in order to measure and improve associate skills that have a direct effect on customer satisfaction. Provides guidance on changes to the law that may impact training and education and require updates to Medicaid Compliance training programs.
• Directs all activities related to contractual performance. Ensures that associates receive detailed, clear and professional performance feedback, in adherence to Policies, SOPs and business protocols. Independently validates performance through focused audits and controls. Develops individual performance measures that support customer satisfaction initiatives. Additional responsibilities include the development of uniform methods and practices in order to measure and improve associate skills and systems performance.
• Prepares status reports communicating compliance activities, identification and correction of problems, trends identified, recommendations and analysis of effectiveness of the Medicaid Compliance programs.
• Collaborates with the Medicaid Compliance officers, as well as the Corporate Compliance team to assure that compliance activities across the organization meet federal, state and organization standards.
• Participates in Enterprise Risk Management activities with Enterprise Risk Management and the Corporate Compliance Integrated Risk Management teams. 

SUPERVISORY RESPONSIBILITY:
This position manages people.

QUALIFICATIONS:

Education Level: Bachelor's Degree in business, healthcare, related area OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience: 

• 8 years progressively responsible corporate compliance, Medicare/Medicaid or government work experience and/or related experience, inclusive of at least 5 years Medicare Part C and/or Medicaid compliance experience.
• 3 years Management experience.

Preferred Qualifications:

• Master's Degree
• Juris Doctor 

Knowledge, Skills and Abilities (KSAs)

• Understanding of business processes and financial control procedures, methods and philosophies coupled with strong analytical reasoning, and problem-solving skills are highly desired.
• Knowledge of compliance program development and maintenance.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
  

  Salary Range: $140,720 - $261,212
  

  Salary Range Disclaimer

  The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

  Department

  Medicare Compliance Office

  Equal Employment Opportunity

  CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

  Where To Apply

  Please visit our website to apply: www.carefirst.com/careers

  Federal Disc/Physical Demand

  Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

  PHYSICAL DEMANDS:

  The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

  Sponsorship in US

  Must be eligible to work in the U.S. without Sponsorship

  #LI-LJ1 

  PDN-a07237f3-d337-4da6-89fc-1af89e41df6b