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Manager, Medicare Operational Compliance - Advantasure

Posted Mar 30
Full Time

Job Description

_Who we are:

_ Advantasure is a growing company and a member of the UST HealthProof family, Advantasure champions innovative solutions with an eye on the future—providing health plans with the flexibility to adapt to a changing regulatory environment and evolving business needs. Leveraging the industry’s leading experts in government-sponsored health plans, Advantasure offers solutions for administrative cost management, quality patient outcomes and experiences, enrollment growth, risk adjustment, and quality and provider engagement initiatives.

We achieve this mission together through teamwork, communication, collaboration, and focus. Our employees are our greatest assets, and we invite you to apply to be a part of our journey toward making a difference in healthcare in the United States.

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You Are

The Manager of Operational Compliance will oversee and maintain Company compliance with contractual and regulatory obligations related to health insurance and managed care. This role serves as primary support to the Director, of Operational Compliance and Audit. The Manager of Operational Compliance will build and manage strategic partnerships with internal business units and external clients toward a common goal of compliance excellence. This role will have a diverse range of compliance-related responsibilities associated with our Medicare line of business. The Manager of Operational Compliance will act as a regulatory resource to clarify, monitor, and research regulatory requirements, provide proactive compliance monitoring and assessments about key initiatives and increase compliance requirements, and collaborate with business areas and vendors to manage corrective action processes when needed and provide ancillary support for client and/or regulatory audits.

This role has team leadership responsibilities and develops and drives our healthcare business compliance monitoring plan activities.

  • Establish a robust monitoring program to assess compliance with regulatory requirements
  • Support business partners by addressing complex operational issues
  • Provide audit support as needed
  • Oversee the Compliance Incident/Inquiry Triage tracking process
  • Prepare and submit required compliance reports to clients and regulatory authorities as necessary
  • Investigate compliance issues, violations, and complaints
  • Manage the Complaint Tracking Management (CTM) process
  • Serve as a subject matter expert on compliance matters
  • Lead and/or support various enterprise strategic initiatives
  • Create, maintain, and enhance the compliance program for Medicare Advantage Plans, including the development of policies, procedures, and controls.

The Opportunity

  • Manage a team of compliance professionals responsible for ensuring compliance excellence.
  • Develop and oversee the compliance monitoring program to ensure adherence to regulatory requirements impacting various operational areas.
  • Perform new and ongoing compliance monitoring activities and support ad-hoc projects.
  • Ensure monitoring is performed to measure compliance with CMS regulations and guidance, communicate findings to impacted business areas, and complete follow-up to ensure resolution of identified issues.
  • Receive, monitor, and resolve CTMs, including investigatory research, outreach to members, and documenting all actions taken in HPMS in accordance with the CTM Standard Operating Procedures (SOP).
  • Review key performance indicators and other monitoring tools, spot trends, and identify potential compliance issues, providing feedback to business areas and escalating when necessary.
  • Coordinate with business areas to review regulations, implement corrective actions if necessary, and track completion.
  • Maintain client dashboards for compliance reporting.
  • Review communication and marketing materials to ensure adherence with CMS regulations and submit to HPMS when necessary for CMS approval.
  • Conduct sales/ agent oversight and monitoring on behalf of the client.
  • Perform Telesales Call Center Accuracy and Accessibility real-time oversight on behalf of the client.
  • Assist in reviewing and preparing responses to CMS and/ or client audits.
  • Collect required attestations and submit them to clients by the established deadlines.
  • Actively participates in the identification of potential Compliance risks for consideration in the department’s annual Risk Assessment process.
  • Lead assigned projects from planning and scoping to delivering results to key stakeholders.
  • Assess potential findings and collaborate with business partners and compliance leadership to develop appropriate solutions for corrective action.
  • Identify opportunities to standardize and streamline compliance monitoring processes.
  • Conduct extensive and thorough analysis of regulatory guidance from various sources to ensure operational compliance initiatives are in alignment with the most current regulatory requirements.
  • Support addressing concerns related to Medicare compliance, privacy, fraud, waste, and abuse, and client contract compliance.
  • Assist in oversight of work performed by delegated vendors to ensure compliance with regulatory and contractual requirements.
  • Maintain current knowledge of laws, regulations, and company strategies to assess impact, and consult with clients as a subject matter expert on compliance matters.
  • Conduct complex investigations, document findings, and ensure corrective actions are implemented.
  • Provide support in the collection and submission of Medicare Part C and D Plan Reporting Data for the purposes of Part C and D Data Validation.
  • Create reports and/or presentations to communicate to organizational leadership.
  • Initiate and lead problem-solving efforts, working closely with internal and external stakeholders.
  • Lead/coordinate compliance committee and review sessions.
  • Build strong relationships with colleagues and business partners to mitigate compliance risks.
  • Lead in the research, analysis, identification, and evaluation of data to assess existing and potential trends and issues,

_This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

_ What You Need

Bachelor’s degree in Healthcare Administration, Public Health, Business Administration, Population Health, Health Informatics, or a related field. A Master’s degree in a related field is preferred. Compliance professional certifications are preferred but not required.

7 or more years’ experience in a Medicare Advantage/ Medicare Part D environment, including experience in the areas of Medicare operations and compliance oversight.

Prior Experience Managing Staff Is Required.

Preference is given to applicants whose experience includes a combination of Medicare Compliance, Medicare Product, and Medicare Part C and D Operations (e.g., enrollment, marketing communications, premium billing, appeals and grievances, claims, utilization management, quality, customer service, STARs, risk adjustment, etc.).

  • Ability to work independently, within a team environment, and communicate effectively with employees at all levels.
  • Ability to synthesize large volumes of data and package them to present to others in a clear and concise manner.
  • Excellent analytical, planning, problem-solving, verbal, and written skills to communicate complex ideas.
  • Ability to correctly assess what needs to be done, perform job responsibilities, and carry out day-to-day activities with minimal supervision.
  • Ability to generate original thoughts and ideas while also being aware of the needs and perspectives of others.
  • Must be highly organized, analytical, and detail-oriented.
  • Excellent interpersonal skills.
  • Must be an effective public speaker, presenter, and communicator with diplomacy and tact.
  • Strong oral and written communication skills.
  • Strong facilitation, collaboration, and teamwork skills with the ability to build cross-functional partnerships to drive results.
  • Must be able to facilitate meetings and achieve consensus regarding work plans and responsibilities.
  • Demonstrate ability to understand and interpret complex regulations.
  • Working experience with PC-based applications such as Excel, PowerPoint, and Word.
  • Excellent time management skills. Strong conflict resolution skills. Process and project management ability.

_Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by local law, UST provides a reasonable range of compensation for roles that may be hired in California, Colorado, New York City, or Washington as set forth below.

_ Role Location: Remote

Compensation Range: $$86,900 to $126,000

What We Believe

_We’re proud to embrace the same values that have shaped UST since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone to champion diversity and inclusion and to place people at the center of everything we do.

_ _Humility: We will listen, learn, be empathetic, and help selflessly in our interactions with everyone.

_ _Humanity: Through business, we will better the lives of those less fortunate than ourselves.

_ _Integrity: We honor our commitments and act with responsibility in all our relationships.

_ _Equal Employment Opportunity Statement

_ _UST is an Equal Opportunity Employer.

_ _All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

_ UST reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance