Principal Clearstone Compliance Consultant

Blue Cross Blue Shield of Minnesota•Eagan, MN

5d•Hybrid

About The Position

This role provides strategic leadership and oversight for the Regional Medicare Prescription Drug Program (Part D), working with the Compliance Office to ensure compliance with CMS, contractual, and applicable state and federal requirements. The position serves as a trusted Medicare compliance advisor to internal leadership, vendors, and clients, with accountability for regulatory interpretation, audit readiness, and continuous improvement of the Part D compliance program. The role is responsible for proactively identifying and mitigating compliance risk, leading CMS audit preparedness and response, overseeing First Tier, Downstream, and Related Entity (FDR) compliance, and translating complex regulatory requirements into practical, business‑aligned solutions.

Requirements

7+ years of related professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
Experience in the health care industry with specific ethics/compliance program knowledge and experience in Medicare Part D Programs
Experience managing project(s) involving multiple team members and including task assignment, working with key customers (internal or external), managing team and/or customer relationships and managing project deliverables.
Detailed knowledge of the development of Government Programs Compliance plans, Medicare Advantage and Medicaid products.
Proven ability to work with CMS/State Regulators.
Knowledge of Health Plan operations on Pharmacy products including claims, enrollment, sales and marketing, health services and membership.
Fundamental knowledge of health insurance regulation at both federal and state levels.
Proven experience in the development and implementation of corporate regulatory compliance and ethics programs.
Significant training experience including program development and implementation.
Well-developed analytical, problem-solving and communication skills.
Business Analysis expertise and ability to translate regulatory requirements into operation.
In depth understanding and experience in application development and submission to the Federal Government on Medicare Products, Advanced understanding of Part D regulatory requirement.
High school diploma (or equivalency) and legal authorization to work in the U.S.

Nice To Haves

Bachelor’s degree

Responsibilities

Establish and maintain a strong and positive working relationship with external client representative(s).
Support client through: Advocating for client through research of internal systems, processes, policies and vendor data to identify root cause and determine appropriate resolution option(s); Providing on-going education, via written or verbal responses, to client to clarify our position regarding company policies and procedures; Serving as first contact and technical expert around client regulatory needs for leadership, internal team members and external client; Reviewing reports and identifying trends in issues impacting client performance and satisfaction; Working with other team members to identify root cause and recommend process and procedural changes to improve member experiences.
Develop, analyze, and provide feedback to processes and reports to oversee and monitor the regional activities to ensure compliance with CMS and contractual requirements.
Work with internal teams, regional vendors, and Alliance Plans to educate, train, and implement self - monitoring, audit and corrective action plans.
Establish and maintain a comprehensive understanding of all new and existing laws, regulations, and other requirements that impact our products and operations in order to provide guidance to analysts on implementation and other compliance strategies.
Manage the identification, interpretation, education, and implementation of Medicare and pharmacy-related regulations.
Review cross functional Policies and Procedures across the enterprise to ensure adherence to compliance requirements.
Ensure CMS required audits are prepared for and completed according to regulatory requirements using assessment tools and corrective action plans.
Develop and implement audit plans, self monitoring, and audit tools to monitor and track compliance.
Lead annual assessments of First-Tier, Downstream, or Related Entities (FDRs)