Director, Compliance(Preferred Experience In Health Plan Operations And Live In Massachusetts)

CareSource•Massachusetts WFH, MA

10d•$113,000 - $197,700

About The Position

The Director, Compliance establishes a baseline of compliance risk, identifies potential areas of exposure, develops compliance risk management strategies aligned with CareSource goals and objectives, and executes an effective compliance program. The role serves as program compliance officer for an assigned CareSource program, maintaining strong relationships with relevant regulators and supporting the Chief Compliance Officer in implementing the compliance program. The Director oversees regulatory and sub-regulatory guidance and changes, regulator requests, audit deliverables, investigations, and implementation of required changes. The role partners with business units and internal support functions to meet compliance requirements, monitor and remediate risk, and interpret and implement applicable federal and state laws, regulations, guidance, contracts, and industry standards concerning Medicaid, Medicare, Marketplace requirements, general compliance, and delegation oversight. The Director contributes to compliance work plans and risk assessments; manages compliance tracking tools and data; oversees corrective action plans, monitoring, and audits; and develops reporting on compliance performance, trends, risks, and improvement opportunities. The position also supports audit readiness and responses, workforce compliance communications and education, a culture of compliance, and an effective HIPAA Privacy compliance program in partnership with the Corporate Privacy Officer. The role reports potential risks and violations to Compliance and plan leadership and provides management and oversight of professional staff.

Requirements

Bachelor’s degree in Business or Healthcare Administration, or a related discipline, or equivalent years of relevant work experience.
At least five years of relevant work experience within health plan operations.
At least three years of management experience.
Experience with Centers for Medicare & Medicaid programs, a State Medicaid Agency program, or a qualified health plan (Marketplace).
Advanced capabilities in Microsoft Office, including Word, Excel, and PowerPoint.
Ability to motivate, influence, and lead matrixed and cross-functional teams.
Excellent relationship management skills and ability to influence risk-management action across a matrix organization.
Excellent oral and written communication skills.
Ability to interact effectively with management at all organizational levels.
Strong analytical, problem-solving, collaboration, and attention-to-detail skills.
Ability to manage ambiguity and integrate, prioritize, and roll out programs without clearly defined guidelines.
Ability to develop, prioritize, and accomplish goals in a fast-paced environment.
Knowledge of the regulatory environment and regulators, including CMS, HHS, DOI, and Medicaid.

Nice To Haves

MBA, Juris Doctorate, or another advanced degree.
At least three years directly involved in government programs or managed care compliance activities.
Working knowledge of the health plan environment.
Certified in Healthcare Compliance (CHC).
Preferred experience in health plan operations and living in Massachusetts.

Responsibilities

Serve as the program compliance officer for an assigned CareSource program and build and maintain a strong relationship with the relevant regulatory entity.
Assist the Chief Compliance Officer and designees with implementation of an effective compliance program.
Oversee regulatory and sub-regulatory guidance and changes, regulator requests, audit deliverables, investigations, and implementation of required changes.
Partner with business units and internal support functions to ensure compliance requirements are met and risk is monitored and remediated through testing, development, implementation, and use.
Stay current on and help interpret and implement applicable federal and state laws and regulations concerning Medicaid, Medicare, Marketplace requirements, general compliance, delegation oversight, and industry standards.
Provide insights for the annual compliance work plan and risk assessment activities.
Manage and drive effective use of compliance tools and data for compliance tracking systems.
Oversee applicable compliance oversight functions, including corrective action plan management, ongoing monitoring, and annual audits.
Develop reporting on key statistics and trends, identify risk mitigation and performance improvement opportunities, and present insights to committees and compliance and company leadership.
Perform data analysis and reporting; maintain oversight reporting mechanisms; track and report outcomes; organize and distribute reports and documents; and recommend enhancements to reporting tools.
Track and trend issues to identify compliance risks and performance improvement opportunities, and provide input for executive compliance reporting.
Assist with regulatory audits and drive audit-readiness activities for the assigned program.
Help teams interpret audit findings, prepare audit responses, and oversee development of effective corrective actions.
Collaborate on compliance alerts, newsletters, and educational materials for the company workforce.
Build effective working relationships and support a culture of compliance based on company core values.
Report potential risks, non-compliance, or alleged violations to Compliance leadership and plan leadership.
Work with business, regulatory, and legal teams to interpret and implement laws, regulations, guidance, contracts, and related regulatory requirements; keep direct-line leadership and the Chief Compliance Officer informed of material initiatives, concerns, operational issues, and remediation.
Manage and oversee professional staff.
Partner with the Corporate Privacy Officer to ensure an effective HIPAA Privacy compliance program that meets federal, state, and accreditation requirements.
Perform other duties as requested.