Director, Health Plan Operational Compliance

Blue Cross NC; Durham (NC); Hybrid; USD 180,000 - 230,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

401k match

Paid Time Off (PTO)

Job summary

Blue Cross NC seeks a strategic leader to guide Health Plan compliance across Medicare, Commercial, and FEP, implementing initiatives that drive efficiencies and compliant outcomes within an enterprise framework.

You will oversee training, reporting, and budgets, collaborating with the Enterprise Compliance Office to resolve issues. The role demands leadership and deep regulatory know-how across a national footprint in Durham, NC.

Qualifications

• Bachelor's degree or Advanced Degree.
• 10 years experience in health insurance, health care operations or legal with at least 4 of those years in a compliance, regulatory and/or Medicare role.
• Detailed knowledge of state and federal insurance law, especially health insurance and managed care.
• 5 years of progressive leadership experience.
• In lieu of degree, 12+ years of experience in related field.

Responsibilities

• Lead the development of the strategy, planning and execution necessary to implement legislation and facilitate implementation of strategies and processes that ensure compliance and achieve operational effectiveness and efficiencies.
• Direct the maintenance and evaluation of an operational compliance program that meets federal guidelines and regulatory requirements and is deployed to all areas of the Health Plan.
• Develop and deploy communication and training initiatives that support operational compliance goals and obligations.
• Establish standards and procedures for reporting and documentation, monitoring results against specifications, investigation and mitigation of compliance issues.
• Partner with the Enterprise Compliance Office to direct compliance issues to appropriate channels for investigation and resolution.
• Lead and oversee management and delivery of enterprise and departmental projects including business case development, ROI analysis, planning, business analysis, and project management.

Skills

Leadership

Compliance

Regulatory knowledge

Project management

Education

Bachelor's degree or Advanced Degree

Job description

Job Description

Provide leadership, vision, and direction for the defined units within their business area, to include Medicare, Commercial, and FEP Compliance. Lead and set goals for teams responsible for identifying, coordinating, and implementing strategies, frameworks, initiatives/projects and activities that create efficiencies, optimize systems & processes, and promote compliant outcomes. Lead multiple teams united to ensure the integrity within the Health Plan that reflects clear alignment to our enterprise compliance program, as well as regulatory and contractual requirements and policies.

Our team creates impact through engagement with business areas to achieve compliant outcomes, including consultative services, project planning, and project leadership, mitigation plan development, compliance audit support and readiness activities, material assurance and agent behavior assurance.

What You'll Do

• Lead the development of the strategy,planningand execution necessary to effectively implement legislation andfacilitateimplementation ofstrategies andprocesses that ensure compliance and achieve operational effectiveness and efficiencies.
• Direct the maintenance and evaluation of an operationalcompliance program that is highly effective, meets federal sentencing guidelines and other regulatory requirements, and is deployed to all areas of theHealth Plan. The ongoing status of the program is reported to management and the governing body throughacommittee structure.
• Develop and deploy communication and training initiatives that supportoperationalcompliance goals and obligations.
• Establishstandards and procedures for reporting and documentation,monitoringresults against specifications,investigationand mitigation of compliance issues.
• In partnership with the Enterprise Compliance Office,collaborate with other BCBSNC staffthroughout the Health Planto direct compliance issues to appropriate channels for investigation and resolution.
• Lead, manage and set goals for teams responsible foridentifying, coordinating, and implementing initiatives/projects and activities thatcreate efficiencies,optimizesystems & processes, and promotecompliant outcomes
• Provide leadership, vision, and direction for assigned teams:
• Accountable for all decisions within the group.
• Determinateam priorities to reflect the organization’s core values and deliverables.
• Develop, coach and motivate others to take actions that support and reflect the core values and desired future state.
• Develop and manage departmental budgets including forecasting and variance analyses.
• Lead initiatives to develop,modify, and improve the effectiveness of the department by looking at processes, root cause analysis, systemenhancements, re-engineering, etc.
• Direct staff of subject matter experts and analysts on supporting business initiatives, production problem resolution, system enhancements,and configurationsto ensure compliant outcomes
• Lead and oversee management and delivery of enterprise and departmental projects including business case development, ROI analysis,planning, business analysis, and project management.
• Lead and oversee optimization of existing systems, processes, and workflowsto ensure compliant outcomes.
• Direct the overall integrity and functionality of departmental business applications and processeso Systemadministrationsupportto includeproviding guidance onconfiguration coding, and oversight of system configurationto ensure compliant outcomes.
• Systemadministrationsupportto includeproviding guidance onconfiguration coding, and oversight of system configurationto ensure compliant outcomes.
• Provideexpertiseand guidance on product implementation and enhancementto ensure compliant outcomes.
• Research, analysis, and user assessment of technology and systems to ensure adequate applicationcapabilities to produce compliant outcomes
• ?Lead andoverseeOperationalCompliancestrategies,programs,training, and/or policy and procedure development and documentation including interfacing withexternal audit programs(e.g.DOI,CMS,otherthirdpartyregulatorybodies).
• Serveasbusinessowner for key corporate, divisional, and departmental initiatives.

What You Have

• Bachelors degree or Advanced Degree
• 10 years experience in health insurance, health care operations or legal with at least 4 of those years in a compliance, regulatory and/or Medicare role.
• Detailed knowledge of state and federal insurance law, especially health insurance and managed care.
• 5 years of progressive leadership experience.
• Experience managing remediation of complex compliance issues and legislative implementations.
• In lieu of degree, 12+ years of experience in related field

Bonus Points

• Strong preference fordualexpertisein:Health CareOperational and Compliance leadership
• Can connectpolicy process compliance outcomes
• Experience influencing or designing workflows/processes

What You'll Get

• The opportunity to work at thecutting edgeof health care delivery with a teamthat'sdeeply invested in the community?
• Work-life balance, flexibility, and the autonomy to dogreat work?
• Medical, dental, and vision coverage along withnumeroushealth and wellness programs?
• Parental leave and support plus adoption and surrogacyassistance?
• Career development programs and tuition reimbursement for continued education?
• 401k match including an annual company contribution?
• Learn more?

Where You'll Work

Our Hybrid Flex approach is builton presencewith a purpose - giving you flexibility to work remotely with intentional in-person connection - that supports a workplacethat'sflexible, connected, and future focused.

In a Hybrid-Flex role, you'll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you'll work virtually, with a few in-office visits each year for meaningful moments that matter.

Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs.Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.