Director, Compliance(Preferred Experience In Health Plan Operations And Live In Massachusetts)

Job Summary:

The Director, Compliance is responsible for establishing a baseline of compliance risk, identifying areas of potential exposure, developing and aligning compliance risk management strategies with CareSource goals and objectives, and executing the compliance program ensuring effectiveness.

Essential Functions:

Serves as the program compliance officer for an assigned CareSource program and will be responsible for building and maintaining a strong relationship and goodwill with the relevant regulatory entity

Assist the Chief Compliance Officer and their designees with the implementation of an effective compliance program

Oversee all activities related to the assigned program’s regulatory and sub regulatory guidance and changes; Ensure timely responses to regulator requests, audit deliverables, and investigations; and ensure required changes are effectively implemented

Build and maintain strong partnerships with business units and internal support functions to help ensure that all compliance requirements have been met; risk is monitored and remediated through testing/ development/ implementation and use

Remain current and help drive interpretation and implementation of federal/state laws and regulations regarding Medicaid, Medicare and Marketplace requirements, as applicable, as well as general compliance and delegation oversight best practices and industry standards

• Provide key insights for the creation and execution of the annual compliance work plan and risk assessment activities
• Manage and drive effective usage of compliance tools and data for the compliance tracking systems
• Oversee assigned program performance of applicable compliance oversight functions such as corrective action plan management, ongoing monitoring, and annual audits

Develop reporting of key statistics and trends of core compliance and oversight functions, identifying risk mitigation and performance improvement opportunities to the Delegation Oversight and Compliance Committees as well as to compliance and company leadership

Perform data analysis and reporting activities. Provide and maintain oversight reporting mechanisms, and track and report outcomes from compliance activities. Collect, organize, and distribute reports and documents and recommend enhancements to reporting compliance tools

• Track and trend issues to identify compliance risk and performance improvement opportunities; provide input for executive compliance reporting
• Assist with regulatory audits and drive audit readiness activities for assigned program
• Assist teams in interpreting audit findings against audit findings, prepare and complete audit responses and oversee the development of effective corrective actions
• Collaborate with internal resources on the production and communication of compliance related alerts, newsletters and educational materials for company workforce
• Establish effective working relationships and build creditability within the organization to support a culture of compliance based on the company's core values
• Report potential risks, non-compliance or alleged violations to Compliance leadership and plan leadership

Work with the business, regulatory and legal to help ensure proper interpretation and implementation of such laws, regulations, guidance, contracts and similar regulatory requirements (collectively “laws”). Ensure direct line leadership and the Chief Compliance Officer are informed of all material regulatory initiatives, compliance concerns, operational issues and associated corrective actions/remediation impacting CareSource

Provide management and oversight of professional staff

Partner with the Corporate Privacy Officer to ensure a comprehensive and effective HIPAA Privacy compliance program is in place to meet federal, state and accreditation requirements

Perform any other job duties as requested

Education and Experience:

Bachelor’s Degree in Business/Healthcare Administration or a related discipline, or equivalent years of relevant work experience are required

Masters of Business Administration (MBA), Juris Doctorate or other advanced degree, is preferred

A minimum of five (5) years of relevant work experience within health plan operations is required, with at least three (3) years directly involved in government programs or managed care compliance activities preferred

Three (3) years of management experience is required

Centers for Medicare & Medicaid program experience, State Medicaid Agency program experience or qualified health plan (i.e. marketplace) experience is required

Competencies, Knowledge and Skills:

Advanced capabilities in MS Office suite including Microsoft Word, Excel and PowerPoint

Ability to motivate, influence, and lead matrixed and cross-functional teams

Excellent relationship management skills that will build and maintain strong working relationships in a matrix environment and influence action across the organization around risk management

• Excellent oral and written communication skills
• Ability to effectively interact with all levels of management within the organization and across multiple organizational layers
• Excellent analysis, attention to detail, and collaboration skills
• Ability to deal with ambiguity - integrate, prioritize and rollout programs without clearly defined guidelines
• Experience in a high-growth business environment
• Working knowledge of health plan environment is preferred
• Strong analytical skills, effective problem-solving skills, and attention to detail
• Ability to work in a fast-past environment
• Ability to develop, prioritize and accomplish goals
• Knowledge of regulatory environment and regulators (CMS/HHS/DOI/ Medicaid)

Licensure and Certification:

Certified in Healthcare Compliance (CHC) preferred

Working Conditions:

General office environment; may be required to sit or stand for extended periods of time