AVP, Medicare Advantage C-SNP Compliance

Impresiv Health•Huntington Beach, CA

4d•Onsite

About The Position

The AVP, Medicare Advantage C-SNP Compliance is responsible for leading and overseeing compliance with Centers for Medicare & Medicaid Services (CMS) Medicare Advantage requirements, Chronic Condition Special Needs Plan (C-SNP) requirements, and applicable federal and state regulations. This position serves as a key compliance authority for the C-SNP program and is responsible for establishing effective compliance controls, monitoring operational performance, identifying regulatory risks, coordinating regulatory and CMS audits, managing corrective actions, and maintaining continuous audit readiness. The AVP will partner closely with Clinical, Operations, Quality, Utilization Management, Network, Pharmacy, Member Services, Enrollment, Marketing, Information Technology, Analytics, delegated entities, and executive leadership to ensure C-SNP requirements are effectively implemented, monitored, and documented.

Requirements

Strong understanding of Medicare Advantage and C-SNP requirements at an operational level.
Ability to translate regulatory requirements into operational policies, procedures, controls, workflows, and measurable accountability.
Ability to identify gaps between regulatory requirements, policies, documentation, and actual business practices.
Demonstrated ability to drive compliance issues through investigation, remediation, validation, and closure.
Strong attention to detail and documentation discipline.
Ability to maintain continuous audit readiness and ensure compliance evidence is complete, accurate, and traceable.
Strong cross-functional leadership skills with the ability to hold business units accountable without relying solely on formal authority.
Sound judgment regarding when compliance concerns require executive or regulatory escalation.
Ability to convert compliance findings into measurable corrective actions and verify completion.
Ability to manage compliance requirements, monitoring mechanisms, accountable owners, supporting evidence, and remediation processes.

Nice To Haves

Experience working directly with CMS or CMS audit contractors.
Experience with SNP Model of Care implementation and monitoring.
Experience with CMS HPMS and Medicare Advantage regulatory communications.
Experience with delegated medical groups, IPAs, MSOs, vendors, or other downstream entities.
Experience in a Medicare Advantage health plan, particularly a startup or rapidly growing plan.
Medicare Advantage compliance certification such as CHC, CHPC, CCEP, or equivalent.
Clinical background such as RN, LPN, social work, or healthcare management.

Responsibilities

Lead compliance oversight for Medicare Advantage and C-SNP regulatory requirements.
Maintain comprehensive knowledge of CMS Medicare Advantage regulations, C-SNP requirements, regulatory guidance, HPMS communications, audit protocols, and applicable federal and state requirements.
Monitor regulatory changes and translate requirements into operational policies, procedures, controls, workflows, and measurable accountability.
Ensure C-SNP operations remain aligned with the approved SNP Model of Care (MOC) and applicable CMS requirements.
Oversee implementation and ongoing compliance with the C-SNP Model of Care, including: Health risk assessments, Individualized care plans, Interdisciplinary care teams, Care coordination and care management, Transitions of care, Beneficiary access and communications, Provider engagement, Quality improvement activities
Establish monitoring processes to identify gaps in Model of Care implementation and ensure deficiencies are documented, corrected, and validated.
Lead organizational readiness for CMS program audits, C-SNP audits, data validation reviews, and other regulatory examinations.
Coordinate responses to CMS, state regulators, auditors, and other oversight organizations.
Ensure regulatory and audit evidence is accurate, complete, timely, and traceable to applicable requirements.
Establish clear ownership for audit responses and corrective actions across business units.
Develop and maintain an ongoing compliance monitoring program covering areas including: Enrollment and eligibility, C-SNP eligibility and qualifying conditions, Member communications, Marketing and sales, Provider requirements, Care management, Utilization management, Quality and Star Ratings, HEDIS, Medication management and pharmacy, Claims and encounter data, Risk adjustment and HCC activities, Grievances and appeals, Access and availability, Member rights and protections, Fraud, Waste and Abuse, Privacy and security, Cultural and linguistic requirements
Prepare regular compliance reports identifying open issues, responsible owners, due dates, risk levels, corrective actions, and escalation requirements.
Establish compliance requirements and monitoring standards for delegated entities, vendors, medical groups, and other downstream organizations.
Review delegated entity audit results, compliance reports, performance metrics, and corrective action plans.
Maintain evidence demonstrating appropriate organizational oversight of delegated functions.
Investigate compliance deficiencies and determine appropriate remediation strategies.
Maintain formal compliance issue and corrective action tracking processes.
Assign accountable owners and measurable completion dates for corrective actions.
Escalate overdue, significant, or high-risk compliance matters to executive leadership and appropriate governance committees.
Validate that corrective actions address the underlying compliance issue and maintain documentation supporting closure.
Develop, review, and maintain compliance policies and procedures consistent with current CMS requirements and operational practices.
Identify gaps between written policies, regulatory requirements, documentation, and actual business processes.
Develop and coordinate compliance training for employees, providers, delegated entities, and applicable contractors.
Provide targeted education when regulatory changes, monitoring activities, or audit findings identify knowledge gaps.
Provide executive leadership and governance committees with regular reporting regarding C-SNP compliance, regulatory changes, audit readiness, Model of Care performance, delegated entity oversight, corrective actions, and emerging regulatory risks.