Senior Health Plan Regulatory Audit Program Manager

Mass General Brigham•Somerville, MA

2d•Hybrid

About The Position

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. Leads MGB Health Plan's audit readiness and execution for all lines of business (Commercial, Medicaid, DSNP, and Medicare Advantage), partnering across internal departments, external vendors, and regulators/auditors. Success in this role is measured by on-time, high-quality submissions, well-managed live audit sessions, clear status/risk reporting to leadership, and timely closure of audit findings through corrective action planning. This position owns the end-to-end external audit life cycle, including audit intake and planning, coordination of SMEs and vendors, evidence/artifact management, response and issue resolution during fieldwork, and tracking corrective action plans through closure. This role sits within Legal, Regulatory Affairs, and Compliance and reports to the Government Programs Compliance Officer. The Sr. External Audit Program Manager is responsible for cataloging the current audits conducted by MGBHP's regulators, creating reasonable project plans to prepare MGBHP for audits, hosting and managing meetings with applicable MGBHP departments and external vendors, and managing project plans to ensure readiness for external audits. Once audits kick off, this role will be responsible for setting up shared sites to store audit artifacts, project-managing department and vendor activities, facilitating internal and vendor meetings, serving as liaison between MGBHP and auditors, and reporting status updates, progress, risks, etc. to the LRAC department, business departments, and senior leaders.

Requirements

Bachelor's Degree required; equivalent years of experience can be considered in lieu of a degree
At least 8-10 years of experience in the federal and state payer insurance industry required
At least 5-7 years of regulatory and compliance experience within a health plan required
At least 2-3 years of deep knowledge of rules and requirements governing Medicare Advantage, Part D, Dual, and Medicaid ACO insurance programs required
At least 2-3 years of experience in performing highly analytical and critical thinking work, including proficiency in Microsoft 365 tools required
At least 1-2 years of knowledge/experience with federal, state, and payer-specific regulations preferred
Exercise self-awareness, monitor impact on others, be receptive to and seek out feedback, and use self-discipline to adjust to feedback.
Build positive relationships with internal and external customers.
Proficient user in Microsoft Office 365 resources
Be accountable for delivering high-quality work.
Act with a clear sense of ownership.
Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value.

Nice To Haves

At least 1-2 years of knowledge/experience with federal, state, and payer-specific regulations preferred

Responsibilities

Maintains an external audit inventory and calendar, including audit type, regulator, key milestones, required data/evidence, and involved departments/vendors.
Defines submission templates and assembly standards (format, naming conventions, version control) and coordinates timely delivery of audit submissions, supplements, and amendments.
In conjunction with the Government Programs Compliance Officer, interacts with regulatory agencies to discuss audit submissions, live audit sessions, reports, corrective actions, and related matters.
Reviews applicable federal and state laws, rules, and regulations to keep apprised of new regulatory developments and how they may impact audit protocols and performance.
Develops, initiates, maintains, and revises policies and procedures for external audit-related activities.
Collaborates with all operational departments to evaluate and enhance audit readiness.
Produces and distributes routine audit status reports (milestones, risks, issues, owners, due dates) to the Government Programs Compliance team, business areas, and senior leadership.
Conducts ongoing risk assessment of audit readiness and performance strengths and gaps that may be detected during an audit.
Partners with business owners and external vendors to remediate audit readiness gaps and track corrective action plans (CAPs) through documented closure.