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Compliance Officer

Job Summary:

The Compliance Officer is an integral position within the Plan. This position is responsible for compliance oversight, administration, and implementation of Medicare Advantage and Medicare Advantage Prescription Drug plans, in accordance with the Plan contract with CMS and the State (covering the SNP and/or MMP plan). The position is responsible to ensure compliance with federal, state and local laws, regulations and policies related to Medicare requirements. The position is responsible for working with the compliance staff in managing all Medicare communications, researching and interpreting regulations, and working with the operational and functional areas to ensure integration of the requirements.

Essential Duties and Responsibilities include the following:

  • Support the achievement of the operations of the Medicare product offerings, to position the Plan for long-term success;
  • Manage access to and retrieval of information from HPMS and other Medicare websites or other sources of information related to Medicare requirements and plan performance metrics.
  • Ensure that Medicare compliance reports are provided to the Corporate Compliance Officer, governing body, CEO, and compliance committee;
  • Ensure staff participation in User Calls and other industry partners with Medicare focus;
  • Service as the primary point of contact with CMS Regional Office staff for day-to-day issues, and for CMS operational audits or other regulatory oversight activities;
  • Ensure Medicare compliance is aware of Medicare daily business activities by interacting with the operational units and providing subject matter expertise to the areas to promote compliance;
  • Oversee development and coordination of educational training programs to ensure that the officers, governing body, managers, employees, first tier, downstream, and related entities (FDR), and other individuals working in the Medicare program are knowledgeable about the compliance program, the written Standards of Conduct, compliance policies and procedures, and all applicable statutory and regulatory requirements;
  • Develop and implement methods that encourage managers and employees to report Medicare noncompliance and potential fraud, waste, and abuse (FWA) without fear of retaliation;
  • Ensure maintenance of the compliance reporting mechanism and effective communication to the Chief Compliance Officer, the Compliance Committee and management
  • Work closely to coordinate internal audit and investigation activities with the Quality Audit team
  • Respond to reports of potential FWA and work with internal investigator and special investigations unit in the development of appropriate corrective action or disciplinary actions;
  • Ensure that the DHHS OIG and GSA exclusion lists have been checked with respect to all employees, governing body members, and FDRs monthly and coordinate any resulting personnel issues with HR and the Corporate Compliance Officer;
  • Ensure that documentation is maintained for each report of potential noncompliance or potential FWA received from any source;
  • Ensure an effective process is in place to document and track self-identified issues, those which were self disclosed to CMS and that BIA are conducted for any that have the potential for beneficiary impact
  • Oversee the development and monitoring of corrective action plans coordinate validation of any corrective actions to ensure remediation is completed;
  • Coordinate potential fraud investigations/referrals with the internal investigator;
  • Collaborate with other sponsors, State Medicaid programs, Medicaid Fraud Control Units, commercial payers, and other organization, where appropriate, when a potential Medicare FWA issue is discovered that involves multiple parties; and
  • Support compliance staff in review, interpretation and management of CMS communications, reporting requirements, and Medicare requirements.

Supervisory Responsibilities:

Supports the Corporate Compliance Officer in the development and implementation of the Medicare Compliance and Ethics Program including the requirements within the program for Medicare. Supervises the Medicare compliance staff in interpretation of requirements, assignment of duties and responsibilities, and coordinating activities. Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:

  • Bachelor’s Degree in Health Care or other related field
  • Solid experience in managed care, health insurance company and/or government healthcare Compliance Program. 5+ years’ experience directly managing a Medicare Compliance Program.
  • Knowledge of federal healthcare laws, regulations and guidance.
  • Solid knowledge of CMS, Medicare Part C and Part D regulations.
  • Ability to work independently, manage multiple projects and meet scheduled deadlines.
  • Ability to identify root cause issues and ensure appropriate corrective actions.
  • Strong analytical and organizational skills with attention to detail.
  • Proficiency in applying and interpreting rules associated with Medicare regulations.
  • Excellent written and verbal communication skills required
  • Ability to effectively lead, supervise and interact with employees in all levels within the organization
  • Advanced degree or certification in audit, pharmacy or compliance discipline preferred


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