Director, Medicare Compliance

Corewell Health • Grand Rapids, MI

1d • Onsite

About The Position

The Medicare Compliance Officer (MCO) is responsible for the development, implementation and oversight of Priority Health's Medicare compliance program. The MCO will report to the Priority Health VP, Compliance & Privacy Officer with a dotted-line to the Priority Health VP, Medicare. The MCO provides advice and counsel to Priority Health and Corewell Health leaders and departments on compliance matters related to Priority Health's Medicare plans. The MCO serves as the point of contact for Priority Health's CMS regional account manager and serves as the organization's subject matter expert regarding CMS program requirements.

Requirements

• Bachelor's Degree in law, business, health care operations/management, information technology/information security, nursing or other clinical area
• 5 years of relevant experience in health care compliance and/or clinical or operational leadership experience.

Nice To Haves

• 3 years of relevant experience in managed care setting
• 3 years of relevant experience in Medicare managed care compliance
• Health plan and government programs experience
• People management experience
• CRT-Healthcare Compliance, Certified (CHC) - HCCA Health Care Compliance Association

Responsibilities

• Responsible for the development, management, implementation and oversight of the Medicare compliance program.
• Responsible for the overall direction, performance and supervision of the Medicare compliance teams.
• Assumes accountability for the team’s deliverables, ensuring the achievement of team goals and objectives in addition to individual goals and objectives.
• Assists in and as needed, directs complex compliance investigations and works with operational leaders and assigned Compliance team members to determine the appropriate handling of such issues.
• May work with external regulatory agencies and legal counsel to resolve compliance issues.
• Serves as the point of contact for Priority Health’s CMS regional account manager.
• Responsible for monitoring developments related to laws and regulations impacting the Medicare Advantage and Prescription Drug Plan, as well as industry trends in Medicare compliance programs.
• Assists in communicating these developments and responsible for leading the development/modification of policies and procedures to accommodate any legal/regulatory changes and updates.
• Serves as Corewell Health’s subject matter expert regarding CMS program requirements, manuals, published guidance, and rules specific to Medicare managed care.
• Leads compliance initiatives and communication of ongoing compliance efforts, risk identification, audit results, and mitigation efforts to further awareness and effectiveness of the Medicare compliance program.
• Performs ongoing Medicare compliance risk assessments as a part of the overall enterprise risk management program.
• Develops and implements the Medicare compliance work plan.
• Presents to various compliance committees, executive leadership meetings, and other meetings as requested on compliance initiatives, audit results and corrective action plans, including the Priority Health Board of Directors.
• Serves as a member of Priority Health’s Compliance Committee, and chair of the Medicare Compliance Subcommittee, as well as leads and participates in associated Medicare compliance subcommittees and internal meetings.
• Collaborates with operational leaders and teams at Priority Health and Corewell Health to change and improve business processes to support, and mitigate risks to, the organization and patient/member rights.
• Collaborates closely with other key internal stakeholders, including medical, pharmacy, risk adjustment, quality, legal, internal audit, and finance departments, leaders and team members.
• Responsible for coordination, planning and participation in any CMS operational, financial or other audits.
• Mentors, coaches and develops direct reports, and acts as a role model and resource.
• Holds staff accountable for high performance against job descriptions, policies & procedures, controls and processes, as well as organizational standards and policies.
• Completes performance reviews, recommends and initiates personnel actions such as interviewing, hiring, performance correction and terminations.

Benefits

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance, pet insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status

What This Job Offers

• Job Type: Full-time
• Career Level: Director