Compliance Lead

Humana

5d • Remote

About The Position

Become a part of our caring community The Compliance Lead ensures compliance with governmental requirements. The Compliance Lead works on problems of diverse scope and complexity ranging from moderate to substantial. The focus of this role is compliance and oversight of clinical UM for Medicare Part C. The Compliance Lead develops and implements compliance policies and procedures. Researches compliance issues and recommends changes that assure compliance with contract obligations. Maintains relationships with government agencies. Coordinates site visits for regulators, coordinates implementation and compliance with corrective action plans, as needed. Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks. Works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action. Key responsibilities may include: Research, understand and apply laws, regulations, and regulatory guidance for HCS operations, including, but not limited to prior authorizations, quality of care, and clinical programs for the Part C Medicare line of business. Serve as the subject matter expert on HCS operations, including, but not limited to prior authorizations, quality of care, and clinical programs for the Part C Medicare line of business. Develop audit methodology and perform auditing and monitoring activity to prevent and detect issues of noncompliance and provide guidance on remedial actions to strengthen compliance controls and ensure compliance with state and federal laws and regulations. Analyze business requirements and complex issues, conduct research, and provide regulatory guidance to business partners, Law, and Enterprise Compliance associates and leaders with regard to HCS operations, including, but not limited to prior authorizations, quality of care, and clinical programs for the Part C Medicare line of business. Develop and track compliance metrics to help monitor and detect potential compliance issues. Partner with Enterprise Compliance team members on regulatory outreach. Serve as the Regulatory Compliance subject matter expert during CMS program audits. Lead onsite program audit preparation and activity and perform oversight of business audit preparation to ensure timely, accurate and complete submission of required data and documentation to regulators. Present findings of monitoring and auditing efforts to business partners and Enterprise Compliance leaders and track issue to ensure appropriate and timely remediation. Lead and participate on committees, providing compliance guidance and direction. Provide back-up and support to other Enterprise Compliance team members and perform other duties, as needed. Use your skills to make an impact

Requirements

• Bachelor's Degree
• 8 or more years of compliance or audit related experience
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Advanced experience with building, collecting, validating, and communicating large sets of data
• Experience with Medicare Part C Clinical Utilization Mgt.

Nice To Haves

• Advanced graduate degree
• Project Management Professional (PMP) certification
• Six Sigma certification
• Leadership experience

Responsibilities

• Research, understand and apply laws, regulations, and regulatory guidance for HCS operations, including, but not limited to prior authorizations, quality of care, and clinical programs for the Part C Medicare line of business.
• Serve as the subject matter expert on HCS operations, including, but not limited to prior authorizations, quality of care, and clinical programs for the Part C Medicare line of business.
• Develop audit methodology and perform auditing and monitoring activity to prevent and detect issues of noncompliance and provide guidance on remedial actions to strengthen compliance controls and ensure compliance with state and federal laws and regulations.
• Analyze business requirements and complex issues, conduct research, and provide regulatory guidance to business partners, Law, and Enterprise Compliance associates and leaders with regard to HCS operations, including, but not limited to prior authorizations, quality of care, and clinical programs for the Part C Medicare line of business.
• Develop and track compliance metrics to help monitor and detect potential compliance issues.
• Partner with Enterprise Compliance team members on regulatory outreach.
• Serve as the Regulatory Compliance subject matter expert during CMS program audits.
• Lead onsite program audit preparation and activity and perform oversight of business audit preparation to ensure timely, accurate and complete submission of required data and documentation to regulators.
• Present findings of monitoring and auditing efforts to business partners and Enterprise Compliance leaders and track issue to ensure appropriate and timely remediation.
• Lead and participate on committees, providing compliance guidance and direction.
• Provide back-up and support to other Enterprise Compliance team members and perform other duties, as needed.

Benefits

• Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees