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Blue Cross & Blue Shield of Rhode Island · 6 hours ago

Director of Medicare & Regulatory Compliance

US RI 500 Exchange

Full-time

Hybrid

Mid, Senior Level

$128K/yr - $212K/yr

7+ years exp

Blue Cross & Blue Shield of Rhode Island is seeking a Director of Medicare & Regulatory Compliance to develop, implement, and monitor compliance programs for Medicare and Medicaid operations. This role involves overseeing compliance programs, managing audits, and ensuring adherence to regulations while providing guidance to staff.

Insurance

Responsibilities

Provide direction and technical guidance to staff. Set goals, review, and evaluate work, and prepare performance reviews

Oversee the corporate Medicare Part C and D compliance programs. Serve as the Medicare Compliance Officer and subject matter expert on CMS rules, policies, and regulation

Oversee the corporate Medicaid compliance program. Serve as the Medicaid Compliance Officer and subject matter expert on RI rules, policies, and regulation

Partner with internal business areas to ensure compliance CMS and Medicaid requirements

Serve as primary relationship manager with CMS and RI Medicaid; respond to inquiries, complaints, and audits. Maintain a regular cadence of meetings with regulators to promote transparency and trust

With the Corporate Compliance Officer, conduct an annual risk assessment and develop an annual compliance audit plan for the company and its delegated vendors against federal, state and accreditation requirements and standards for all lines of business. Develop and oversee corrective action plans to remediate audit findings and monitor the implementation of corrective action plans

Ensure the timely and accurate submission of all regulatory filings and reports related to CMS and RI Medicaid

Develop and maintain internal processes to promptly review new regulations, interpret the regulation as it relates to company operational units; communicate regulations to the impacted business areas and ensure implementation of requirements

Coordinate annual and ad-hoc training to company associates related to Medicare requirements

Provide reporting and updates to the corporate compliance officer regarding company and New England Joint Enterprise (NEJE) Medicare and Medicaid compliance activities

Manage all CMS and RI Medicaid audits and site visits. Develop corrective action plans to remediate audit findings and monitor operational department’s implementation of such plans

Represent the company on the NEJE regional compliance workgroup and execute all compliance monitoring deliverables assigned to company. Collaborate with NEJE team members to address areas of non-compliance and work with vendor to remediate findings. Escalate areas of continued non-compliance within NEJE compliance structure

Develop and ensure adherence to goals and deadlines

Perform other duties as assigned

Qualification

Medicare complianceMedicaid complianceCompliance auditsHealthcare regulationsCertified in Healthcare ComplianceLeadership experienceInfluencing skillsTeam motivationBudget managementNegotiation skills

Required

A combination of education and related experience

Seven to ten years of experience in Medicare or corporate compliance within the health insurance industry

Five or more years of management experience or experience leading a team

Experience designing, conducting, and monitoring compliance audits

Strong knowledge of compliance principles, practices and procedures

Knowledge of health insurance operations and healthcare issues, including managed care

Knowledge of government healthcare programs (Medicare, Medicaid)

Working knowledge of Medicare Part C and Part D requirements

Knowledge of Pharmacy Benefit Manager (PBM) operations

Ability to collaborate while dealing with complex situations

Ability to think creatively and to drive innovation

Ability to influence up and across the organization

Ability to motivate, lead and inspire a diverse group to a common goal/solution with multiple stakeholders

Ability to convert business strategy into action-oriented objectives and measurable results

Ability to develop and manage a budget

Strong negotiating, influencing, and consensus-building skills

Ability to mentor, coach and provide guidance to others

Preferred

Certified in Healthcare Compliance (CHC) or Certified Compliance and Ethics Professional (CCEP), Compliance & Ethics Professional Certification (CCEP)

Experience interpreting and applying state and federal laws and regulations

Knowledge of BCBSRI lines of business