Manager Medicaid Compliance

Company :

Job Description : 

JOB SUMMARY

** MUST be a US Citizen ***

This leadership role ensures the organization's robust compliance with all applicable federal and state Medicaid and CHIP regulations, including the growing number of laws and regulations governing managed care organizations. The Manager, Medicaid Compliance & Operations acts as a trusted business partner, providing expert advice and guidance on Medicaid and CHIP compliance matters, and directly contributing to the efficient and effective operational execution of program requirements. This includes defining program structure, educational/training requirements, reporting and compliance mechanisms, response and correction procedures, and compliance expectations for all personnel and related entities supporting core functions of Medicaid and CHIP contracts. The position actively manages the day-to-day operations of the Medicaid Compliance Program, and contributes to the operational workflow for compliance functions, proactively identifies and mitigates compliance risks, and fosters a strong culture of compliance within the organization. This role works closely with operational teams to ensure compliance requirements are embedded within operational workflows, and performance standards are met.

ESSENTIAL RESPONSIBILITIES

• Medicaid Compliance Program Oversight & Operational Integration:

  • Manage the day-to-day operations of the Medicaid and CHIP Compliance Program.

  • Develop and maintain policies and procedures to foster a culture of compliance; continually monitor and evaluate the adequacy and efficacy of policies, procedures, and company adherence.

  • Assess risk through a formal risk assessment process and develop and implement an annual audit plan to monitor and ensure compliance with Medicaid and CHIP laws and regulations. Refresh the audit plan quarterly to assess changes to the risk assessment.

  • Oversee the development of Quality Action Plans and compliance work plans.

  • Act as a liaison between UCD Legislative Affairs and operations teams on Medicaid/CHIP compliance requirements and business impacts.

  • Serve as the external audit lead contact for Medicaid/CHIP audits.

  • Oversee Corrective Action Plans (CAPs) to ensure root cause analysis, remediation, and process improvements are made within operational areas.

  • Assist with Medicaid and CHIP partnership implementations, coordinating with Legislative Affairs to research state requirements and documentation.

  • Provide PA CHIP operations compliance oversight.

  • Collaborate with operational teams to design and implement workflows that ensure compliance requirements are seamlessly integrated into daily activities.

  • Monitor key operational performance indicators (KPIs) related to Medicaid/CHIP compliance and identify areas for improvement.

  • Participate in operational meetings to provide compliance guidance and support.                                                      

• Regulatory Monitoring and Communication:

  • Monitor regulatory agencies (federal and state) for changes in laws, requirements, etc., relevant to Medicaid and CHIP programs and communicate changes to affected business unit(s), monitoring for conformity within required timeframes.

  • Translate regulatory changes into actionable steps for operational teams and provide ongoing support to ensure successful implementation.                                                  

• Training and Education:

  • Create and implement educational training programs to ensure understanding of the Medicaid and CHIP Compliance Program and all applicable statutory and regulatory requirements.                                                                               

• Risk Management and Reporting:

  • Develop and implement methods and programs that encourage managers and employees to report Medicaid/CHIP program noncompliance and suspected fraud, waste, and abuse (FWA) and other misconduct without fear of retaliation.

  • Respond to reports of potential instances of FWA, including coordinating internal investigations and developing appropriate corrective or disciplinary actions, as necessary.

  • Work with business units or third-party vendors to determine the root cause of risks and resolve issues through modified procedures, training, systems, or disciplinary actions. Coordinate and serve as a liaison during compliance audits and exams.

  • Develop and maintain a comprehensive risk register that identifies potential operational vulnerabilities related to Medicaid/CHIP compliance.

  • Work with operational teams to implement mitigation strategies to address identified risks and monitor their effectiveness.                                                          

• Collaboration and Reporting:

  • Work with various governance committees, policy workgroups, other infrastructure areas, and businesses on all aspects of the Compliance Program, including initiatives, project management, reporting, and monitoring.

  • Provide regular reports to the Government Compliance Officer and Chief Compliance Officer on the status of the Medicaid and CHIP Compliance Program.

  • Coordinate and summarize the efforts and activities of the Medicaid and CHIP Compliance Program for the Government Compliance Officer to communicate to the internally developed Executive Compliance Committee and Audit Committee.

  • Prepare regular reports on operational compliance performance for senior management, highlighting key trends and areas for improvement.                                                           

• Other duties as assigned or requested.                                                                       

EXPERIENCE

Required

• * Must be a US Citizen

• 5 years of experience in Health Care Field

• 3 years of experience in applicable government business compliance (Medicare, Medicaid, or Marketplace) ​

Preferred

• None

SKILLS

• Broad-based business knowledge as well as in-depth knowledge of the insurance industry, strategic compliance planning, regulatory concerns, compliance requirements, and Corporate Integrity principles

• Experience with managed care, Medicare and Federal and/or State regulations, quality improvement and compliance oversight.

• High-level of skill in leading interdepartmental and cross-functional strategy development

• Excellent oral, written, and presentation skills

• Conceptual and analytic skills are necessary in order to review and articulate corporate objectives and Federal regulations across all relevant audience

• The ability to comprehend and interpret regulatory, legislative, and contractual mandates

• Compliance and/or regulatory experience with proven ability

• Simultaneous manage multiple projects

• The utmost integrity in the discreet and confidential handling of confidential materials is necessary

• Experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met

EDUCATION

Required

• Bachelor’s Degree in Business, Healthcare or other related area or relevant experience and/or education as determined by the company in lieu of bachelor's degree.   

Preferred

• Masters Degree in Business, Healthcare, or other related area

LICENSES or CERTIFICATIONS

Required

• None

Preferred

• None

Language (Other than English):

None

Travel Required:

Less than 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based or Remote Position

Physical work site required

Frequently

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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