Senior Director – Auditing – Monitoring & Oversight – Medicare

Senior Director – Auditing – Monitoring & Oversight – Medicare

Requirements

• Bachelor’s Degree Business Administration, Public Policy, Public Health, Health Administration or related field; or equivalent experience required
• 10+ years Compliance for a managed care or health insurance company or equivalent experience required

Responsibilities

• Establish a process for overseeing compliance with regulations and laws related to Medicare requirements
• Provides guidance to various business departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contractual language
• Conducts compliance reviews and manages team that conducts compliance reviews, assisting with identification of issues and collaborating with Corrections team for remediation of issues
• Performs risk assessments and report emerging trends, deficiencies and variances, report findings to other departments and teams as appropriate
• Oversee team responsible for monitoring against regulatory requirements ensures sufficient monitoring activities to assist with prevention and proactive identification of compliance concerns
• Develops and monitors metrics and other oversight tools that indicate business area compliance
• Provides compliance guidance, direction and compliance risk assessment to assigned business partners
• Manages and develops direct reports who include other management or supervisory personnel and/or exempt individual contributors
• Plan and collaborate with other teams and leaders on complex projects/programs necessitating the origination and application of new and unique approaches
• Set operational priorities including the development and maintenance of effective oversight activities and prioritization of work
• Responsible for Board and Executive reporting related to responsibilities of the team and compliance of business operations for which you oversee
• Educates, encourages, and assists those within the company to maintain integrity through correction of identified non-compliance to meet the requirements of Government-sponsored health care programs
• Participates in mock and actual CMS and other regulatory audits and coordinates with Internal Audit, Regulatory Compliance and/or Market based Regulatory Affairs on responses to agency inquiries and oversees the internal and external processes required to ensure the Company maintains a consistent state of Audit readiness
• Maintains a current working knowledge of various laws, regulations, and industry guidance that impacts the health industry generally, and government programs in the health sector specifically, including fraud and abuse and anti-kickback statutes, OIG and government health plan guidelines and state marketing compliance laws, prompt pay, provider adequacy and other laws
• Makes decisions on complex issues regarding technical approach for project components and can work without significant direction
• Performs other duties as assigned
• Comply with all policies and standards.

Preferred Qualifications

• CPA, CISA, JD, MHA, MBA, MIS preferred
• 7+ years Management experience preferred
• HCCA certification (CHC) or equivalent preferred