Director, Medicare Compliance/ Job Req 788830920 (Sales)

PRINCIPAL RESPONSIBILITIES:
The Director of Medicare Compliance is responsible for developing, implementing, and overseeing all activities related to ensuring compliance with Medicare regulations, CMS requirements, and applicable federal laws governing Medicare Advantage and Part D programs. This position serves as the subject matter expert for Medicare compliance and reports directly to the Chief Compliance Officer & Chief Privacy Officer (CCO/CPO). The Director of Medicare Compliance leads the development of Medicare-specific compliance strategies, policies, and procedures while managing a team dedicated to Medicare compliance monitoring, auditing, and risk mitigation at the Alameda Alliance for Health.
Principal responsibilities include:
MEDICARE COMPLIANCE PROGRAM REQUIREMENTS:

Develop, implement, and maintain the Medicare Compliance Program to ensure adherence to Medicare Advantage and Part D regulations, CMS guidance, federal laws, and contractual obligations.
Create and execute an annual Medicare compliance work plan that includes comprehensive risk assessments, monitoring activities, and auditing schedules aligned with CMS expectations.
Establish and maintain a Medicare-specific risk register to identify, assess, and prioritize compliance risks within Medicare operations.
Support the CCO/CPO in Medicare compliance committee activities, preparing agendas, presentations, and follow-up materials.
Coordinate with operational departments to implement effective Medicare compliance controls and ensure proper documentation of compliance activities.
Prepare and present regular Medicare compliance reports to senior leadership, the Compliance Committee, and Board committees as requested.
Lead the organization's preparation for CMS program audits, mock audits, and validation audits.
Manage Medicare compliance staff, providing guidance, mentorship, and professional development opportunities.
Serve as the primary liaison with CMS and other regulatory agencies for Medicare compliance matters.
Represent the compliance department in Medicare operational meetings to provide compliance guidance.

POLICIES, PROCEDURES AND STANDARDS:

Develop, implement, and maintain Medicare-specific policies, procedures, and standards to ensure compliance with Medicare regulations and CMS guidance.
Monitor federal regulatory changes affecting Medicare Advantage and Part D programs and update internal policies and procedures accordingly.
Collaborate with operational departments to develop and implement Medicare compliance controls and workflows.
Establish Medicare compliance standards and metrics to measure program effectiveness.
Support the integration of Medicare compliance requirements into the organization's enterprise risk management framework.

EDUCATION AND TRAINING:

Develop and implement comprehensive Medicare compliance training for employees, leadership, Board members, first tier, downstream, and related entities (FDRs).
Design specialized Medicare fraud, waste, and abuse (FWA) training programs in accordance with CMS requirements.
Conduct targeted training for operational areas on specific Medicare compliance requirements and emerging regulatory issues.
Provide guidance and education to operational departments regarding Medicare compliance requirements and best practices.
Keep informed of changes in Medicare regulations, industry trends, and best practices through ongoing education and professional development.

MONITORING AND AUDITING:

Develop and implement a comprehensive Medicare monitoring and auditing program based on risk assessments and regulatory requirements.
Oversee the execution of routine Medicare compliance audits, including Part C and Part D program audits.
Lead the review of Medicare data submissions to ensure accuracy, completeness, and timeliness.
Monitor compliance with Medicare marketing guidelines and materials development.
Oversee FDR oversight activities, including pre-contracting assessments, annual attestations, and ongoing monitoring.
Coordinate with Internal Audit on Medicare-focused audits and remediation activities.
Review and analyze Medicare compliance metrics, performance data, and monitoring results to identify trends and areas requiring intervention.
Oversee excluded provider screening processes specific to Medicare programs.

INVESTIGATION AND CORRECTIVE ACTION:

Lead investigations into potential Medicare compliance issues, working collaboratively with Legal and other departments as appropriate.
Develop and implement effective corrective action plans (CAPs) to address identified Medicare compliance issues.
Track and monitor the implementation and effectiveness of Medicare-related CAPs.
Manage the process for self-reporting of compliance issues to CMS as required.
Coordinate responses to CMS audit findings and other regulatory inquiries.
Provide guidance on remediation strategies for identified Medicare compliance issues.

FIRST TIER, DOWNSTREAM, AND RELATED ENTITIES (FDR) OVERSIGHT:

Develop and implement a comprehensive FDR oversight program that meets Medicare requirements.
Establish processes for pre-contracting assessments, annual attestations, and ongoing monitoring of FDRs.
Provide guidance and education to FDRs regarding Medicare compliance requirements.
Monitor FDR compliance with Medicare requirements, including exclusion screening, training, and reporting.
Coordinate with Procurement and Legal in the development of Medicare compliance language for FDR contracts.

ESSENTIAL FUNCTIONS OF THE JOB

Update, develop, implement, document, and maintain organization-wide compliance program as necessary.
Update, develop, implement, and maintain organizational policies, procedures, and standards.
Coordinate and initiate internal audits.
Compliance education and training of staff.
Monitor, track, and audit the compliance program, identify risks, and ensure departmental compliance on an ongoing basis.
Initiate investigations and corrective action plans

PHYSICAL REQUIREMENTS

Constant and close visual work at desk or computer.
Constant sitting and working at desk.
Constant data entry using keyboard and/or mouse.
Frequent use of telephone headset.
Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
Frequent lifting of folders and various other objects weighing between 0 and 30 lbs.
Frequent walking and standing.
Occasional driving of automobiles.

Number of Employees Supervised: 2-5
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:

Bachelor's degree required in business, healthcare administration, public health, law, or related field.
Master's degree or JD preferred.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

Minimum of 7 years of experience in healthcare compliance, with at least 4 years specifically focused on Medicare Advantage and/or Part D compliance.
Minimum of 3 years of management experience leading compliance teams.
Experience with CMS program audits, validation audits, and/or mock audits.
Experience developing and implementing Medicare compliance programs, policies, and procedures.
Direct experience with a large health plan (500,000+ members) preferred

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

Medicare compliance certification (such as CHC, CCEP, or AHIP Medicare certification) strongly preferred.
Comprehensive knowledge of Medicare regulations, including 42 CFR Parts 422 and 423, Medicare Managed Care Manual, Prescription Drug Benefit Manual, and related CMS guidance.
Strong understanding of healthcare operations, including claims processing, enrollment, appeals and grievances, pharmacy benefit management, and care management.
Thorough knowledge of compliance program effectiveness and the seven elements of an effective compliance program.
Excellent analytical and problem-solving skills with the ability to identify compliance risks and develop practical solutions.
Strong project management skills with the ability to manage multiple priorities in a fast-paced environment.
Exceptional written and verbal communication skills, including the ability to explain complex regulatory requirements to diverse audiences.
Demonstrated leadership abilities, including team development, coaching, and performance management.
Proficiency with Microsoft Office applications and familiarity with compliance monitoring and reporting tools.
Ability to establish credibility and build collaborative relationships across all levels of the organization.
Strong ethical standards and commitment to integrity in all aspects of the compliance program.
Strong influencing skills and perseverance in investigating.
Demonstrates high integrity and excellent judgment.
Extensive experience with public assistance programs and public agencies. Experience in use of various computer system software as well as Windows, Microsoft Word, Microsoft Excel, Microsoft Outlook and Microsoft PowerPoint

SALARY RANGE $193,980.80- $290,971.20 Annually
The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws..