Lead Director, Medicaid Compliance External Audits – Texas

CVS Health

8d • $100,000 - $231,540

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary: As a Lead Director of Medicaid Compliance and External Audits, you are in a senior level compliance position responsible for the management, execution, and oversight of a high volume of external audits, ad hoc state requests and inquiries, and associated internal and external CAPs for a highly complex Medicaid managed care market. In this role you oversee the activities of other compliance team members assigned to the market and maintains matrices responsibility for managing and reviewing state deliverables prepared by shared service partners and business leads from across Aetna Medicaid. You are primarily responsible for developing and maintaining systems and processes to manage the health plan’s preparation, response, and successful completion of a high volume of complex external regulatory audits, ad hoc state inquiries and escalated state issues or requests.

Requirements

• 10 years previous experience in Medicaid or Medicaid managed care
• 2+ years previous experience managing external audits
• 2+ previous management experience
• 5+ years regulatory compliance position in managed care, health care, or insurance or 3 years with Master’s Degree
• Ability to travel (up to 25% - including plane) to Texas for audit preparations and on-site reviews
• Regular and reliable attendance due to time sensitive nature of external deliverables and activities
• Bachelor’s Degree; equivalent years of related professional work experience may substitute

Nice To Haves

• Project management experience
• Located within the state of Texas (or willingness to relocate)
• Master’s degree preferred in Public Policy, Health Care Administration, Public Administration or similar fields or a law degree

Responsibilities

• Serving as the principal liaison to the state Medicaid agency for all external audits and escalated state matters, ensuring effective compliance and contract-related communication and activities within a highly regulated and complex Medicaid health plan.
• Facilitating the preparation for and management of external audits conducted by state Medicaid and related agencies or partners through final report and corrective action plan closure
• Supervising the submission of all audit deliverables and ad hoc state requests or escalated issues, ensuring that strategic and quality reviews are conducted prior to submission to address compliance-related concerns, appropriate escalations are made to executive leaders for deliverables that fail to meet all requirements, and collaborate with health plan counsel to facilitate appropriate legal review
• Conducting comprehensive lessons learned evaluations following post-audit and develop proactive corrective actions with executive leaders to address identified deficiencies prior to issuance of the final report.
• Conducting research and develop recommendations to help executive leadership across Aetna Medicaid develop compliant business operations, processes and policies in accordance with state specific Medicaid program requirements
• Independently developing compelling, strategic, and appropriate compliance related communications on behalf of the health plan in response to state Medicaid agency audit-related inquiries or requests and escalated state issues
• Maintaining an in-depth working knowledge of the health plan’s contractual, regulatory, and program policy related obligations as a Medicaid managed care organization and serve as a resource to health plan and growth partner staff through the preparation, submission, and response to external audits, ad hoc inquiries, and escalated state requests.
• Designing and managing tools for tracking and handling complex state external audits and escalated issues, including deliverable assignments, deadlines, internal reporting and summaries, risk monitoring, and analyses of findings; Ensure these resources are user-friendly and accessible to business partners to support effective and efficient audit preparation and completion.
• Utilizing systems unique to job functions, including standard-issue software such as Microsoft products and compliance specific tools such as Archer or QuickBase
• Maintaining positive, productive relationships with internal and external senior level constituents to effectively communicate and influence ethical and compliant outcomes
• Providing training and guidance to less experienced team members to accomplish goals
• Other duties as assigned

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

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