Sr Mgr, Medicare Compliance

PURPOSE OF THE JOB

· The Senior Manager, Medicare Compliance will manage the day-day-day activities of the Medicare Compliance department, which engages in monitoring the company’s compliance with requirements pertaining to Medicare Advantage and Prescription Drug plan, and Medicare Supplement product lines and segments. Serves as the secondary point of contact for Centers for Medicare and Medicaid Services (CMS) for Medicare products. Responsible for ensuring

overall compliance with all Medicare compliance activities and programs. Will report directly to the Staff Vice President of Corporate and Medicare Compliance, and Medicare Compliance Officer.

REQUIRED QUALIFICATIONS

1. Required Work Experience

· 8 years of experience with government or compliance, or legal issues

2. Required Education

· Bachelor’s Degree in compliance, health administration, legal studies, or other related field of study

3. Required Licenses

· N/A

4. Required Certifications

· N/A

PREFERRED QUALIFICATIONS

1. Preferred Work Experience

· 10 years of experience with compliance, government programs or legal issues in a healthcare industry

2. Preferred Education

· Master’s Degree in business or healthcare field of study

3. Preferred Licenses

· N/A

4. Preferred Certifications

· Advanced compliance professional, audit, or legal training

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Manage the day-to-day operations of the department.
• Control and direct workflow to staff in a timely manner, including internal and external compliance reviews / audits.
• Oversee internal, initial and final compliance review/audit reports. Maintain records of compliance investigation/audit activity and track to ensure all work papers within each investigation/review/audit are accurately controlled.
• Administer, interpret, and maintain current working knowledge of the required AZ Blue systems, procedures, forms and manuals as related to the assigned area of responsibility.
• Responsible for the review, update and accuracy of Compliance documentation, computer files, policies and procedures related to the department goals and objectives.
• Keep staff informed of new or updated standards, systems, procedures, forms and manuals through staff meetings and verbal and written communications.
• Direct, evaluate, define, and improve the quality, quantity and timeliness standards to achieve individual and department performance goals as defined within department guidelines.
• Develop and maintain competent staff to carry out assigned functions.
• Provide guidance, motivation, and encouragement to staff, conduct performance evaluations, identify and coordinate training needs, and make determinations regarding disciplinary actions.
• Plan, monitor and coordinate direct activities needed to support corporate goals and objectives.
• Evaluate and make recommendations in regard to employment decisions.
• Consult and coordinate with various internal departments, external Blue Plans or business partners and government agencies where appropriate for all Medicare compliance activities and programs as well as plans, implements and monitors the organization’s Medicare compliance program.
• Prepare and execute annual Medicare Compliance Work Plan.
• Act as a compliance liaison with the Centers for Medicare and Medicaid Services (CMS), maintaining a positive relationship with the CMS Account Manager/Regional Office.
• Prepare for and respond to CMS and other external audits.
• Manage Medicare Program requirements, such as Health Plan Management System (HPMS) submissions.
• Prepare and executive a comprehensive Medicare Compliance Program and Work Plan for the organization, including responding to all compliance questions or concerns; developing and distributing compliance training programs for the organization’s employees, and First Tier, Downstream and Related Entities (FDRs).
• Works collaboratively with Internal Audit to ensure internal controls are in place and that internal monitoring, auditing and oversight functions are being performed, and that deficiencies are fixed.
• Participate in all BCBSAZ required training, Blue Gives Back and professional seminars/training.
• Maintain compliance review tools, reports, and correspondence templates.
• Represents BCBSAZ at industry conferences and presents best practices.
• Manages projects with multi-disciplinary teams.
• Assists management of Compliance as required on other projects / tasks.
• Performs all other duties as assigned.
• Arizona residence and weekly on-site office presence is required. Additional on-site office presence may also be required.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.

REQUIRED COMPETENCIES

1. Required Job Skills

· Intermediate PC proficiency.

· Intermediate proficiency in spreadsheet, database, presentation and word processing software.

· Organizational skills and strong logical thinking ability.

2. Required Professional Competencies

· Advanced knowledge of ethical and regulatory compliance.

· Analytical skills to support independent and effective decisions.

· Prioritize tasks and work with multiple priorities, sometimes under limited time constraints.

· Perserverance in the face of resistance or setbacks.

· Effective interpersonal skills and ability to maintain positive working relationship with others.

· Verbal and written communication skills and the ability to interact professionally with a diverse group, executives, managers, and subject matter experts.

· Ability to create and deliver employee education of complex regulatory and ethical issues in an understandable way.

· Maintain confidentiality and privacy.

· Analytical knowledge necessary to generate reports based on available data and then make decisions based on reported data.

· Maintain confidentiality and privacy.

· Communicate professionally to both internal and external customers.

· Analyze and research data, propose solutions to resolve issues.

· Establish, contribute and maintain a positive and productive work environment.

· Ability to plan, organize and manage the work of all assigned personnel.

· Ability to collaborate and think globally.

· Must possess strong interpersonal skills, as well as effective oral and written communication skills.

3. Required Leadership Experience and Competencies (All Levels)

· Take appropriate risks using available data

· Build synergy with a diverse team in an ever-changing environment.

· Optimize resources to ensure a cost-effective operation. Includes proactively planning to move staff from one role to another as staffing needs, business priorities or workload changes.

· Build efffective teams.

· Implement new processes and procedures.

· Persuade and instill effective cooperation and compliance. Develop rapport and facilitate cooperation, as well as apply corrective actions.

PREFERRED COMPETENCIES

1. Preferred Job Skills · Advanced PC proficiency · Advanced proficiency in spreadsheet, database, presentation and word processing software · Ability to establish and maintain professional relationships with community and professional groups which reflect favorably for the department and AZ Blue.

2. Preferred Professional Competencies (All Levels)

· Expert knowledge of ethical and regulatory compliance.

· Ability to work with ambiguous and conflicting information while keeping focused on the end goal.

· Ability to coordinate activities of several departments to resolve issues.

3. Preferred Leadership Experience and Competencies

· N/A