Director, Contract Compliance

ourhrconnect; Columbia (SC); Híbrido; USD 90.000 - 130.000; Jornada completa

Descripción de la vacante

BlueCross BlueShield of South Carolina is seeking a Pharmacy Benefit Compliance role focused on state and federal requirements, URAC and NCQA oversight. The position handles regulatory compliance across states and coordinates policy forms and filings.

Located in Columbia, SC, this full-time role follows a hybrid schedule: three days onsite and two days remote, based at 4101 Percival Road. The team works on ensuring HIPAA, ERISA, and anti-money laundering controls align with evolving regulations.

Formación

• Bachelor's degree in a related field.
• 10 years claims, customer service, compliance administration or health insurance industry related experience.
• 3 years demonstrated leadership experience in a supervisory/management role or equivalent.
• Familiarity with audit procedures and regulations.

Responsabilidades

• Develops plans for major business opportunities and assesses potential partners.
• Designs and implements privacy and security compliance programs in line with federal and state requirements.
• Directs contract language reviews across jurisdictions and coordinates policy issuance.
• Oversees agent licensing, HIPAA/ERISA compliance, and compliance program activities.
• Manages filing of policy/certificate language with Insurance Commissioners in all jurisdictions.
• Coordinates development of policy language and revisions for the product portfolio.
• Maintains advertising files in accordance with state regulations.

Conocimientos

Leadership

Regulatory compliance understanding

Audit awareness

Healthcare industry knowledge

Educación

Bachelor's degree in a related field

Descripción del empleo

Why should you join the BlueCross BlueShield of South Carolina family of companies?

Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina ... and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose:

This role will focus on pharmacy benefit compliance regarding state and federal requirements. In addition, this role will support internal oversight of the department regarding URAC and NCQA requirements. Responsible for assessing major business opportunities and potential business partners and corresponding to compliance issues. Manages and coordinates all in-state and out-of-state corporate and contractual requirements and policy form filings as they relate to regulatory compliance in all operating states and the District of Columbia. Manages policy/certificate issuance software. Supervises agent licensing and appointment functions, complaint handling, Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security, and Employment Retirement and Insurance Security Act (ERISA) compliance.

Logistics: BlueCross and BlueShield of South Carolina.

Location: This is a full-time position (Monday through Friday, 40 hours per week) that operates on a hybrid work schedule, to include three days onsite and two days work at home. This role is located at 4101 Percival Road in Columbia, SC 29229.

What You'll Do :

• Develops solutions and plans of action for major business opportunities. Assesses and evaluates potential business partners.
• Designs and implements Privacy and Security compliance programs. Assists management in developing policies and procedures consistent with federal and state requirements and implementing necessary changes. Directs the implementation of the Patriot Act compliance initiative.
• Ensures all claimants receiving claim checks have been screened against the list of Prohibited Persons published by the Office of Foreign Asset Control. Oversees Anti-Money Laundering initiative. Ensures that high-risk products and distribution channels receive an increased level of Anti-Money Laundering scrutiny.
• Directs the preparation and approval of all contract language for agency contracts, endorsements, certificates and booklets in all jurisdictions in which agency is authorized to do business. Coordinates the development of agency benefits with Senior Management and external personnel. Initiates revisions to existing and renewal contracts, certificates, and booklets in all operating jurisdictions to comply with changes in agency operations and to improve clarity and intent of the documents.
• Coordinates and directs the drafting of all policy and certificate language for the company's product portfolio. Implements all policy and certificate revisions and coordinates the review with all appropriate areas. Distributes and disseminates changes in contracts to Senior Management and Directors of all business units.
• Directs the filing of all contract language with the Insurance Commissioners in all jurisdictions where agencies operate. Obtains approval of all agencies' policies, certificates, applications, and actuarial information necessary to conduct the business of insurance. Gains admission into new states where the company wishes to do business, coordinating activities with Executive Management, Senior Staff, and the Legal Department as appropriate.
• Responsible for the policy and certificate issue system. Writes and oversees the writing of programming logic to ensure the correct language/benefits are issued depending on state of issuance, benefits requested type of policy, and line of business.
• Maintains advertising files in accordance with state advertising regulations.
• Directs Agent Licensing Department. Ensures all producers are appropriately licensed and appointed to represent agency and have current contracts including the requisite HIPAA Business Associate Agreement.
• Reviews incoming memoranda, bulletins, etc. from State Insurance Departments and federal government to determine company position and response.

To Qualify For This Position, You'll Need The Following :

• Bachelor's in a job-related field
• 10 years claims, customer service, appeals, compliance administration or health insurance industry related experience.
• 3 years demonstrated leadership experience in a supervisory/management role or equivalent military experience in grade E4 or above (may be concurrent).
• Familiarity with audit or compliance procedures and regulations. Strong custo