Director, Contract Compliance

BlueCross BlueShield of South Carolina•Columbia, SC

6d•Hybrid

About The Position

The Director, Contract Compliance focuses on pharmacy benefit compliance with state and federal requirements and supports internal oversight of URAC and NCQA requirements. The role assesses major business opportunities and potential business partners, addresses compliance issues, and manages corporate and contractual requirements and policy form filings across operating states and the District of Columbia. It also oversees the policy and certificate issuance system, agent licensing and appointments, complaint handling, HIPAA Privacy and Security, and ERISA compliance. The position directs development and filing of contract, policy, and certificate language; coordinates policy and contract revisions; oversees regulatory filings and state admissions; and manages related compliance programs, including Patriot Act and Anti-Money Laundering initiatives. It is based in Columbia, South Carolina, and follows a hybrid schedule of three days onsite and two days working from home, Monday through Friday, 40 hours per week.

Requirements

Bachelor’s degree in a job-related field.
10 years of claims, customer service, appeals, compliance administration, or health insurance industry-related experience.
3 years of demonstrated leadership experience in a supervisory or management role, or equivalent military experience at grade E4 or above; experience may be concurrent.
Familiarity with audit or compliance procedures and regulations.
Strong customer service orientation.
Ability to communicate effectively verbally and in writing with all organizational levels.
Excellent analytical, critical-thinking, and problem-solving capabilities.
Ability to work in a highly changing environment and to persuade, negotiate, or influence.
Ability to exercise confidentiality and discretion.
Excellent presentation skills and strong attention to detail.
Ability to interpret and implement complex and ambiguous government rules.
Microsoft Office skills.

Nice To Haves

Experience with pharmacy benefit compliance.
Knowledge of state and federal healthcare regulations.
Familiarity with URAC or NCQA accreditation standards.
Experience supporting compliance audits, reviews, or oversight activities.

Responsibilities

Develop solutions and plans of action for major business opportunities and assess potential business partners.
Design and implement Privacy and Security compliance programs; assist management with policies and procedures consistent with federal and state requirements and implement necessary changes.
Direct implementation of the Patriot Act compliance initiative.
Ensure claimants receiving claim checks are screened against the Office of Foreign Asset Control’s Prohibited Persons list.
Oversee the Anti-Money Laundering initiative and ensure high-risk products and distribution channels receive increased scrutiny.
Direct preparation and approval of contract language for agency contracts, endorsements, certificates, and booklets in all jurisdictions where the agency is authorized to do business.
Coordinate development of agency benefits with senior management and external personnel.
Initiate revisions to existing and renewal contracts, certificates, and booklets to reflect operational changes and improve clarity and intent.
Coordinate and direct drafting of policy and certificate language for the company’s product portfolio, implement revisions, and coordinate reviews with appropriate areas.
Distribute and communicate contract changes to senior management and business-unit directors.
Direct filing of contract language with Insurance Commissioners and obtain approval for policies, certificates, applications, and actuarial information required to conduct insurance business.
Coordinate the company’s admission into new states with Executive Management, Senior Staff, and the Legal Department as appropriate.
Manage the policy and certificate issuance system and oversee programming logic that determines language and benefits based on state of issuance, requested benefits, policy type, and line of business.
Maintain advertising files in accordance with state advertising regulations.
Direct the Agent Licensing Department and ensure producers are appropriately licensed and appointed, have current contracts, and have the required HIPAA Business Associate Agreement.
Review memoranda, bulletins, and other materials from state insurance departments and the federal government to determine the company’s position and response.