Government Programs Compliance Specialist, Senior

Blue Shield of CA; Oakland (CA); On-site; USD 120,000 - 180,000; Full time

Job summary

Blue Shield of California is seeking a Government Programs Compliance Specialist, Senior to support the Medicare Compliance Program through risk-based monitoring and audits. You will evaluate plan materials for accuracy and regulatory alignment, identify compliance risks, and collaborate with business teams to drive corrective action in a fast-paced environment.

The role requires deep CMS/DHCS knowledge, a bachelor’s degree or equivalent, and at least five years of relevant Medicare compliance

Qualifications

• Requires a bachelor's degree or equivalent experience.
• Minimum of 5 years of relevant experience conducting compliance reviews of Medicare Advantage and Part D plan marketing and member communications.
• Deep knowledge of CMS and DHCS compliance requirements for plan member and marketing materials.
• Excellent organizational skills.
• Strong independent judgment, problem solving and analytical abilities.
• Ability to work collaboratively in a team and deliver quality work in a regulated environment.
• Proficiency in Word, Access, Excel, PowerPoint, Outlook, SharePoint, and HPMS.
• Project management experience preferred; CHC certification preferred.

Responsibilities

• Provide risk-based monitoring, audits, and compliance activities for Medicare programs.
• Evaluate accuracy and integrity of plan materials and identify compliance risks.
• Partner with business teams to promote regulatory compliance and corrective action.

Education

Bachelor's degree or equivalent experience

Tools

Microsoft Office Suite

SharePoint

HPMS

Job description

Your Role

The Medicare Compliance team is responsible for providing oversight of Blue Shield's Medicare Advantage and Part D plan operations to help ensure compliance with CMS regulations, contractual requirements, and internal policies. The Government Programs Compliance Specialist, Senior will report to the Senior Manager, Government Programs - Medicare Compliance. In this role, you will help support the effectiveness of the Medicare Compliance Program through risk-based monitoring, audits, and compliance activities that include evaluating the accuracy, completeness and integrity of plan materials, identifying compliance risks, and partnering with business teams to promote regulatory compliance and corrective action.

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience

• Requires a minimum of 5 years of relevant experience conducting compliance reviews of Medicare Advantage and Part D plan marketing and member communication materials

• Requires a deep knowledge of the Centers for Medicare & Medicaid Services' (CMS) compliance requirements for Medicare Advantage and Part D plan member and marketing materials, as well as the Department of Health Care Services' (DHCS) compliance requirements for exclusively aligned enrollment dual special needs plan member and marketing materials.

• Requires excellent organizational skills.

• Requires strong independent judgment, problem solving, critical and analytical skills, including an exceptional \"moral compass\" and work ethic.

• Requires ability to work collaboratively in a team, perform duties with minimal supervision, multi-task, and to deliver a quality product in a highly regulated, demanding, and constantly changing corporate environment.

• Requires proficiency in Microsoft Office suite programs (Word, Access, Excel, PowerPoint and Outlook), SharePoint, and the Health Plan Management System (HPMS).

• Project management or similar experience is preferred

• Professional certification (CHC - Certification in Healthcare Compliance) is preferred

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.