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

CareSource; Massachusetts; On-site; USD 113,000 - 198,000; Full time

Benefits offered by this job

Bonus tied to performance

Job summary

CareSource is seeking a Director of Compliance to establish baseline compliance risk, identify exposures, and align risk management strategies with company goals. The role leads the compliance program to ensure effectiveness and regulatory readiness.

Responsibilities include oversight of regulatory guidance, audits, corrective actions, and reporting to leadership. Requires MS Office proficiency, strong communication, and extensive experience in health plan compliance with CMS/Medicaid knowledge.

Qualifications

• Bachelor’s degree in Business/Healthcare Administration or related field.
• MBA, JD or other advanced degree preferred.
• Minimum five (5) years in health plan operations; at least three (3) years in government programs or managed care compliance preferred.
• Three (3) years of management experience required.
• Centers for Medicare & Medicaid program experience, State Medicaid Agency program experience or qualified health plan (i.e. marketplace) experience preferred.

Responsibilities

• Serve as program compliance officer for an assigned CareSource program and build strong relationships with regulators.
• Assist CCO with implementing an effective compliance program.
• Oversee regulatory guidance and changes; respond to regulator requests, audits, and investigations.
• Build partnerships with business units to ensure compliance requirements are met and risks are remediated.
• Drive interpretation and implementation of federal/state laws regarding Medicaid, Medicare and Marketplace requirements.

Skills

MS Office Suite (Word/Excel/PowerPoint

Leadership in matrixed environments

Regulatory knowledge (CMS/HHS/DOI/Med—

Communication skills

Education

Bachelor’s Degree in Business/Healthcare Administration or related discipline

MBA or JD or other advanced degree preferred

Job description

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 affecting 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 detailAbility 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

$113,000.00 - $197,700.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level.

• In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
• We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Salary

Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.