Director, Contract Compliance

BlueCross BlueShield of South Carolina•Columbia, SC

4d•Hybrid

About The Position

The Director, Contract Compliance focuses on pharmacy benefit compliance with state and federal requirements and supports internal oversight of department compliance with URAC and NCQA requirements. The role assesses major business opportunities and potential business partners, and manages corporate and contractual requirements and policy form filings in operating states and the District of Columbia. It also manages policy and certificate issuance software and oversees agent licensing and appointments, complaint handling, HIPAA Privacy and Security, and ERISA compliance. The Director develops solutions for major business opportunities, evaluates business partners, designs and implements privacy and security compliance programs, and helps management maintain policies and procedures consistent with applicable requirements. The position leads Patriot Act and Anti-Money Laundering initiatives, oversees contract and policy language development and filings, coordinates product benefit development, and ensures appropriate policy and certificate issuance. The role also directs agent licensing, monitors regulatory communications, and supports compliance with applicable state and federal requirements. This is a full-time position based in Columbia, South Carolina, on a hybrid schedule: 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 with other experience requirements.
Familiarity with audit or compliance procedures and regulations.
Strong customer service orientation.
Ability to communicate effectively verbally and in writing at all organizational levels.
Excellent analytical, critical-thinking, and problem-solving capabilities.
Ability to work in a highly changing environment and 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 proficiency.

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 developing and updating policies and procedures consistent with federal and state requirements.
Direct implementation of the Patriot Act compliance initiative and 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 authorized jurisdictions.
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 drafting of policy and certificate language for the company’s product portfolio, implement revisions, and coordinate reviews with appropriate areas.
Distribute changes in contracts to senior management and business-unit directors.
Direct filing of contract language with insurance commissioners and obtain approval of policies, certificates, applications, and required actuarial information.
Coordinate activities to gain admission into new states with executive management, senior staff, and Legal as appropriate.
Manage the policy and certificate issuance system, including overseeing programming logic that ensures correct language and benefits are issued based on jurisdiction and product details.
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 required HIPAA Business Associate Agreements.
Review memoranda, bulletins, and other communications from state insurance departments and the federal government to determine the company’s position and response.
Supervise complaint handling, HIPAA Privacy and Security, and ERISA compliance functions.