Program Manager, Medicare Compliance

About the Role

The day-to-day responsibilities of this role are multifaceted, encompassing the management of regulatory affairs, prevention, detection, and correction of compliance issues. This includes ensuring that all employees are trained on compliance policies and procedures, managing the compliance hotline, and conducting preliminary reviews and investigations into alleged compliance violations. The Program Manager will also be responsible for developing and maintaining strong working relationships with business partners and regulatory bodies, ensuring timely and accurate submissions of CMS-required documents, and establishing readily accessible communication channels for compliance-related matters.

Given the critical nature of this role, the ideal candidate will possess a deep understanding of CMS requirements and regulations related to Medicare Advantage and Part D operations. They will have a proven track record in managing compliance programs, preferably within a healthcare insurance or CMS government program environment, and demonstrate strong knowledge of the seven elements of an effective compliance program.

What You Will Do

• Analyze business needs and identify potential compliance risks, ensuring effective communication of issues and assisting in remediation efforts.
• Develop and maintain strong working relationships with internal and external stakeholders, including business partners and regulatory bodies.
• Oversee the development and implementation of compliance programs, policies, and procedures to ensure adherence to regulatory requirements.
• Ensure that all employees are trained on compliance policies and procedures, promoting a culture of compliance throughout the organization.
• Manage the compliance hotline, ensuring that all compliance-related concerns are addressed promptly and appropriately.
• Conduct preliminary reviews and investigations into alleged compliance violations, taking corrective action as necessary.
• Develop and maintain a system for uniform response, enforcement, and corrective action on matters relating to Medicare Advantage compliance.
• Ensure timely and accurate submissions of CMS-required documents, maintaining a high level of compliance with regulatory requirements.
• Establish and oversee readily accessible communication channels for compliance-related matters, including a compliance hotline.

What We Are Looking For

• Bachelor's degree in a related field, with a preference for certification in Health Care Compliance or a related field.
• Minimum seven years of government compliance experience in a healthcare insurance or CMS government program environment, or a Master's degree in a related field with minimum five years of experience.
• Minimum three years of direct Medicare Advantage compliance experience, with a strong understanding of CMS requirements and regulations.
• Minimum two years of leadership experience, with proven ability to manage teams and projects effectively.
• Strong knowledge of CMS regulations pertaining to compliance in a managed care health plan, including the Medicare Managed Care Manual.
• Experience with CMS Program Audits, financial audits, data validation audits, CMS reviews, and CMS’ HPMS modules.
• Excellent oral and written communication skills, with the ability to present complex information effectively.
• Strong analytical and problem-solving skills, with the ability to identify and mitigate compliance risks.

Nice to Have

• Experience in a related field, such as healthcare law or compliance consulting.
• Certification in a related field, such as Certified Healthcare Compliance (CHC) or Certified Compliance Professional (CCP).
• Strong understanding of the seven elements of an effective compliance program and the CMS methodology of Prevent, Detect, and Correct.
• Experience with compliance software and systems, including compliance tracking and reporting tools.

Benefits and Perks

• Competitive salary and benefits package, including health, dental, and vision insurance.
• Opportunity to work with a leading healthcare organization, making a meaningful impact on the lives of patients and communities.
• Collaborative and dynamic work environment, with a strong focus on teamwork and professional development.
• Flexible work arrangements, including remote work options and flexible hours.
• Access to cutting-edge technology and tools, including compliance software and systems.
• Professional development opportunities, including training and certification programs.
• Recognition and reward programs, including bonuses and incentives for outstanding performance.

• Ensure your resume and cover letter are tailored to the specific requirements of the Program Manager, Medicare Compliance role, highlighting your experience in compliance program development and management.
• Develop a strong understanding of CMS regulations and requirements, including the seven elements of an effective compliance program and the CMS methodology of Prevent, Detect, and Correct.
• Prepare examples of your experience in managing compliance programs, including your approach to risk assessment, mitigation, and remediation.
• Research Arkansas Blue Cross's compliance program and policies, demonstrating your knowledge and understanding of the organization's commitment to compliance.
• Be prepared to discuss your leadership experience, including your approach to team management, project management, and stakeholder engagement.
• Consider obtaining certification in a related field, such as Certified Healthcare Compliance (CHC) or Certified Compliance Professional (CCP), to demonstrate your expertise and commitment to the field.
• Practice your communication skills, preparing to present complex compliance information effectively to both technical and non-technical stakeholders.