The Project Director is an integral position within the Plan. This position is responsible for providing subject matter expertise on Medicare Part C and D in order to effectively support 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 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:
- Subject matter expertise in an operational function of Medicare Part C and/or D
- Ability to review, interpret and implement state and federal guidance
- Support compliance staff in review, interpretation and management of CMS communications, reporting requirements, and Medicare requirements.
- Oversee audit programs to confirm compliance with guidance.
- 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;
- Oversee and administer ongoing monitoring program(s) based on guidance
- Updates policies and procedures needed.
- Adhere to established corporate policies and procedures
- Perform other duties, as necessary, to meet corporate objectives
- Travel maybe required
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 with a minimum of five (5) years government, health care, pharmacy benefit management, compliance or quality profession (equivalent combination of education and experience considered.)
- 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
- Advanced degree or certification in audit, pharmacy or compliance discipline preferred
- Must work well under tight timelines and adapt quickly to change in a fast-paced, team-oriented, and high-growth environment.