Director, Medicaid Compliance and Regulatory Affairs

Overview

Plans, implements, and directs compliance activities for one or more VNS Health Plans insurance plans and products. This includes the development, implementation, and oversight of policies and practices to ensure that the organization complies with applicable federal, state, and local regulations. Oversees the annual compliance work plan to ensure consistency among all plans and products, as well as alignment with the VNS Health Standards of Conduct.

Ensures that new VNS Health Plans ventures are planned and implemented consistent with New York State and federal regulations and organizational policies and procedures. Works under general direction. Assigned portfolio includes VNS Health Plans Medicaid products (HIV SNP, MLTC, MAP), with primary responsibility for applicable New York State Medicaid regulatory requirements and state regulator relationships.

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 3
• 0 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities
• This role requires an on-site presence in New York three days per week

What You Will Do:

• Reviews and evaluates new regulations and practices to ensure that internal policies are consistent with federal and state regulations. Serves as a subject matter expert to the program and related corporations.
• Gathers information regarding current practices, trends, potential areas of compliance vulnerability, and risks used to develop and maintain the health plan-related aspects of VNS Health Plans’ Compliance Work Plan. Works with other staff and leadership to ensure effective implementation of the VNS Health Plans Compliance Program.
• Collaborates with Product teams and other business owners to develop and implement corrective action plans for the resolution of problematic issues.
• Ensures that all new regulations related to VNS Health Plans health plans are distributed throughout the organization. Establishes protocols and guidelines for oversight of these implementations, including ongoing monitoring or auditing as needed.
• Addresses health plan compliance-related reports, inquiries, investigations, audits, and surveys received through or performed by internal and external sources.
• Identifies the need for education related to compliance with laws, regulations, and policies applicable to the health plans; collaborates with department leadership in the development of training for staff.
• Participates with other VNS Health staff in interacting with social, governmental, health, and community agencies to identify and influence public policy issues that relate to the health plans. Represents VNS Health Plans internally and externally and increases public awareness of the program through education, presentations, and marketing of services.
• Creates and maintains an environment that encourages reporting of concerns and allegations throughout the organization in a non-punitive manner; serves as a resource to staff regarding compliance-related matters and questions.
• Performs all duties inherent in a senior managerial role. Ensures effective staff training, evaluates staff performance, provides input for the development of the department budget, and hires, promotes, and terminates staff and recommends salary actions, as appropriate.
• Ensures compliance with all federal and applicable state laws and regulations related to the governance of assigned VNS Health Plans insurance plans and products.
• Implements and coordinates audits consistent with the Compliance Work Plan. Assesses and monitors progress on areas of regulatory exposure through monitoring, audits, and discussions with management. Develops periodic reports of findings for senior leadership, including the President and the VNS Health Plans Board of Directors. Refines performance measures based on audit findings.
• Acts as a resource for VNS Health Plans staff regarding regulations, contracts, and policies applicable to assigned insurance plans and products. Researches policy and regulatory questions, when necessary, including consultations with applicable government representatives, as well as internal and external attorneys.
• Participates in the annual risk assessment process and development of auditing and monitoring plans.
• Participates in external audits to ensure that all deliverables are reviewed and submitted in a timely manner and that business units are prepared to present to regulators.
• For the assigned Medicaid portfolio, ensures compliance with all federal and applicable state laws and regulations related to the governance of New York State Medicaid Health Insurance Plans.
• For policy and regulatory questions involving the assigned Medicaid portfolio, consults as necessary with government representatives from DOH, OMIG, and OMH, as well as internal and external attorneys.
• Participates in special projects and performs other duties as assigned.

Qualifications

• Licenses and Certifications: Valid driver's license or NYS Non-Driver photo ID card may be required as determined by operational/regional needs.
• Education: Master's degree in nursing, health administration, public health, social work or other related field required
• Work Experience: Minimum eight years of progressively responsible compliance, regulatory, or policy-related experience required
• Minimum five years of managerial experience required
• Strong knowledge of state, federal, and other governmental regulations and requirements governing long-term care and managed care programs required
• Strong written and verbal communication and interpersonal skills required
• Experience in health care compliance or program development in home- and community-based care, long-term care, or managed care preferred

Pay Range

USD $154,400.00 - USD $205,800.00 /Yr.

About Us

VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We’re one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.

Responsibilities

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 3
• 0 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities
• This role requires an on-site presence in New York three days per week

What You Will Do:

• Reviews and evaluates new regulations and practices to ensure that internal policies are consistent with federal and state regulations. Serves as a subject matter expert to the program and related corporations.
• Gathers information regarding current practices, trends, potential areas of compliance vulnerability, and risks used to develop and maintain the health plan-related aspects of VNS Health Plans’ Compliance Work Plan. Works with other staff and leadership to ensure effective implementation of the VNS Health Plans Compliance Program.
• Collaborates with Product teams and other business owners to develop and implement corrective action plans for the resolution of problematic issues.
• Ensures that all new regulations related to VNS Health Plans health plans are distributed throughout the organization. Establishes protocols and guidelines for oversight of these implementations, including ongoing monitoring or auditing as needed.
• Addresses health plan compliance-related reports, inquiries, investigations, audits, and surveys received through or performed by internal and external sources.
• Identifies the need for education related to compliance with laws, regulations, and policies applicable to the health plans; collaborates with department leadership in the development of training for staff.
• Participates with other VNS Health staff in interacting with social, governmental, health, and community agencies to identify and influence public policy issues that relate to the health plans. Represents VNS Health Plans internally and externally and increases public awareness of the program through education, presentations, and marketing of services.
• Creates and maintains an environment that encourages reporting of concerns and allegations throughout the organization in a non-punitive manner; serves as a resource to staff regarding compliance-related matters and questions.
• Performs all duties inherent in a senior managerial role. Ensures effective staff training, evaluates staff performance, provides input for the development of the department budget, and hires, promotes, and terminates staff and recommends salary actions, as appropriate.
• Ensures compliance with all federal and applicable state laws and regulations related to the governance of assigned VNS Health Plans insurance plans and products.
• Implements and coordinates audits consistent with the Compliance Work Plan. Assesses and monitors progress on areas of regulatory exposure through monitoring, audits, and discussions with management. Develops periodic reports of findings for senior leadership, including the President and the VNS Health Plans Board of Directors. Refines performance measures based on audit findings.
• Acts as a resource for VNS Health Plans staff regarding regulations, contracts, and policies applicable to assigned insurance plans and products. Researches policy and regulatory questions, when necessary, including consultations with applicable government representatives, as well as internal and external attorneys.
• Participates in the annual risk assessment process and development of auditing and monitoring plans.
• Participates in external audits to ensure that all deliverables are reviewed and submitted in a timely manner and that business units are prepared to present to regulators.
• For the assigned Medicaid portfolio, ensures compliance with all federal and applicable state laws and regulations related to the governance of New York State Medicaid Health Insurance Plans.
• For policy and regulatory questions involving the assigned Medicaid portfolio, consults as necessary with government representatives from DOH, OMIG, and OMH, as well as internal and external attorneys.
• Participates in special projects and performs other duties as assigned.

Qualifications

• Licenses and Certifications: Valid driver's license or NYS Non-Driver photo ID card may be required as determined by operational/regional needs.
• Education: Master's degree in nursing, health administration, public health, social work or other related field required
• Work Experience: Minimum eight years of progressively responsible compliance, regulatory, or policy-related experience required
• Minimum five years of managerial experience required
• Strong knowledge of state, federal, and other governmental regulations and requirements governing long-term care and managed care programs required
• Strong written and verbal communication and interpersonal skills required
• Experience in health care compliance or program development in home- and community-based care, long-term care, or managed care preferred