Government Programs Compliance Lead

Blue Cross and Blue Shield of Kansas Inc.; Chicago (IL); Hybrid; USD 114,000 - 154,000; Full time

Benefits offered by this job

Annual bonus incentive

Medical/dental/vision insurance

11 holidays

401(k) matching

Paid time off

Job summary

Blue Cross and Blue Shield of Kansas Inc. is seeking a Government Programs Compliance Lead to support the Medicare Compliance Officer by implementing CMS-aligned programs and seven elements across Part C and Part D.

The role focuses on policies, training, monitoring, audits, and remediation, partnering with operational teams to embed compliant processes. The position emphasizes risk assessment, regulatory gap analyses, CAP design, and actionable guidance for claims, pharmacy, utilization

Qualifications

• Deep knowledge of CMS Medicare regulations and guidance including 42 CFR Parts 422/423, CMS manuals, HPMS guidance, and audit protocols.
• Understanding of the 7 Elements of an Effective Compliance Program and how to operationalize them.
• Knowledge of Medicare Part D and/or MA-PD program requirements including enrollment, claims, formulary, pharmacy operations, and member protections.
• Knowledge of Fraud, Waste, and Abuse requirements and detection methodologies.
• Ability to conduct regulatory gap analyses and translate requirements into actionable controls.
• Strong auditing and monitoring capabilities and data-driven oversight.
• Knowledge of CMS audit processes and audit-readiness expectations.
• Ability to interpret regulatory requirements for practical guidance to stakeholders.
• Strong governance and reporting skills including board-level oversight.
• Effective communication and documentation skills.
• Knowledge of privacy and data governance in Medicare contexts.
• Ability to manage internal stakeholders and FDRs.

Responsibilities

• Support the Medicare Compliance Officer in executing and improving the compliance program aligned with CMS requirements and seven elements.
• Operationalize program elements: policies, training, monitoring, audits, and corrective actions across Part C and Part D.
• Serve as primary compliance liaison to operational teams ensuring regulatory alignment in day-to-day activities.
• Assess compliance risks in core areas impacting claims, utilization management, pharmacy, enrollment, and grievances/appeals.
• Support ongoing risk assessment activities, CAP development, and reporting to committees and leadership.

Skills

CMS Regulations

7 Elements

Part D/MA-PD

FWA Knowledge

Auditing & Monitoring

CAPs Design

CMS Audits

Governance & Reporting

Clear Communication

Privacy & Data Governance

Stakeholder Management

Analytical Skills

Integrity & Judgment

Education

Bachelor's degree

Job description

## Government Programs Compliance LeadApplylocations: US IL Chicago E. Randolphtime type: Full timeposted on: Posted 3 Days Agojob requisition id: JR5915Job Description Summary: The Compliance Lead for Government Programs serves as a senior subject matter expert supporting the Medicare Compliance Officer in executing and continuously enhancing the compliance program in alignment with CMS requirements and the seven elements of an effective compliance program. This role drives the operationalization of key compliance functions including policies and procedures, training, monitoring and auditing, and issue investigation and remediation while proactively identifying and mitigating compliance risks across Medicare Advantage (Part C) and Part D operations. Acting as a primary liaison to operational teams, the position translates complex regulatory requirements into practical, embedded business processes, ensures compliance integration into day-to-day activities, and provides expert guidance across core functional areas such as claims, pharmacy, utilization management, and appeals, with a strong emphasis on enterprise risk assessment and regulatory alignment.**Responsibilities include but are not limited to:*** Support the Medicare Compliance Officer in the execution and continuous improvement of the compliance program, ensuring alignment with CMS requirements and the 7 elements of an effective compliance program, with a focus on proactive risk identification and mitigation. Operationalize compliance program elements, including: Policies and procedures development and implementation, Training and awareness initiatives, Monitoring, auditing, and data-driven oversight, Issue identification, investigation, and corrective action planning* Provide deep subject matter expertise in Medicare Part C and/or Part D operations, with the ability to assess compliance risks within core functional areas (e.g., claims processing, utilization management, pharmacy operations, coverage determinations, grievances/appeals)* Serve as the primary compliance liaison to Association Medicare operational teams, ensuring alignment with regulatory requirements across Medicare Advantage (Part C) and Part D programs, including oversight of compliance integration within day-to-day operations. Experience supporting EGWP plans is strongly preferred* Partner with operational and business teams to translate Medicare regulatory requirements into actionable, operational processes, ensuring compliance is embedded into workflows across key operational functions* Support ongoing risk assessment activities, incorporating insights from audits, FDR monitoring, and committee reporting to continuously enhance compliance program effectiveness and proactively address emerging regulatory risks**The posting range for this position is:**113,572.92 - 153,590.12**Required Education, Certifications and Experience:**Education:* Required BSExperience:* Required 7+ YearsKnowledge Skills and Abilities:* Deep knowledge of CMS Medicare regulations and guidance (including 42 CFR Parts 422/423, CMS manuals, HPMS guidance, and audit protocols)* Understanding of the 7 Elements of an Effective Compliance Program and ability to operationalize them across Medicare Advantage and Part D programs* Knowledge of Medicare Part D and/or MA-PD program requirements including enrollment, claims, formulary, pharmacy operations, and member protections* Knowledge of Fraud, Waste, and Abuse (FWA) requirements and detection methodologies including exclusion screening, investigations, and reporting obligations* Ability to conduct regulatory gap analyses and translate requirements into actionable controls across operational functions (e.g., claims, UM/CM, network, enrollment)* Strong auditing and monitoring capabilities including development of work plans, identification of compliance risks, and use of data-driven oversight* Ability to design, implement, and evaluate corrective action plans (CAPs) ensuring timely remediation and sustainable compliance outcomes Knowledge of CMS audit processes and audit-readiness expectations including document production, universes, and issue remediation lifecycle* Ability to interpret and apply regulatory requirements to complex business scenarios and provide practical, risk-based compliance guidance to operational stakeholders Strong governance and reporting skills including experience supporting compliance committees, senior leadership reporting, and Board-level oversight* Effective communication skills with the ability to translate regulatory requirements into clear guidance, training, and business-friendly language* Knowledge of privacy, data governance, and handling of sensitive information particularly as it relates to Medicare data and compliance investigations* Ability to manage relationships with internal stakeholders and FDRs to ensure compliance expectations are understood, implemented, and monitored* Strong analytical and problem-solving skills with the ability to identify root causes of compliance issues and recommend sustainable solutions* High level of professional integrity and judgment including the ability to identify, escalate, and address potential compliance risks or noncompliance#LI\_HYBRIDThe posted salary range is the lowest to highest salary we, in good faith, believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the hiring range and this hiring range may also be modified in the future. A candidate’s position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs. This job is also eligible for *annual bonus incentive* pay.We offer a comprehensive package of benefits *including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account and many other benefits* to eligible employees.Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.