Vice President, Compliance

Vice President, Compliance

Chicago, IL

Our Client is a respected and financially strong insurance carrier with a national presence. You would have an opportunity to be part of the expansion of this division if you were selected to join the leadership team.  Making a difference in healthcare is what we they do, are you ready to be part of something unique?

The Vice President, Compliance, functions independently to provide oversight and guidance to the Board and senior management team regarding risk management, regulatory guidance, and policies and procedures to protect and grow the Company's business interests of Medicare Advantage.

Contributes to the overall Medicare Advantage strategy, provides guidance and recommendations to internal and external business partners to develop, maintain and enhance Medicare Advantage programs, products and service.

Responsibilities  

You will oversee and direct regulatory and compliance functions for health plan operational areas, serves as liaison with regulatory authorities (Centers for Medicare and Medicaid Services (CMS) and State Insurance Depts.) relative to Medicare compliance program activities.

You will be responsible for the development and implementation of the Medicare compliance program structure, compliance education/training, auditing and monitoring program, reporting and compliance mechanisms. 

Responsible for response and correction procedures for compliance issues and compliance expectations for all personnel and first tier, downstream and related (FDR) entities that support core functions of contracts with CMS. 

You review and interpret proposed and ongoing regulations, and ensures effective compliance activities, policies and practices.

You will evaluate compliance with Medicare regulations applicable to Company operations and consults with Senior Leadership regarding deviations and solutions to ensure corporate compliance.

Implements and directs the audit, monitoring, verification and mitigation of compliance risks associated with Medicare Advantage. Oversees various audits conducted internally and externally, particularly CMS audits.

Ensures that risk assessments with Medicare Advantage are conducted in accordance with CMS audit guidelines and other applicable regulatory bodies. Plans and executes CMS audit readiness and assessment of program effectiveness.

You will prepare reports and submit results to Senior Leadership and Board of Directors for review, follow-up, and recommendations for action.

This includes overseeing and directing Medicare Advantage Fraud, Waste and Abuse (FWA) program to ensure compliance with Medicare and other state regulatory requirements.

You develop and oversees a process for uniform handling of Medicare Advantage compliance matters. Collaborates with other departments to direct compliance issues to appropriate existing channels for investigation and resolution.

Oversees Medicare Advantage vendors, third parties and consultants to ensure delegated activities are compliant with Medicare and other regulatory requirements with respect to compliance. 

Maintains education, awareness, and knowledge of current Medicare regulations, best practices within the industry and the management of health plan operations. Brings regulatory changes and matters of significance or urgency to the attention of Senior Leadership and facilitates necessary changes for compliance to improve business practices.

You serve as a resource for internal business partners by continuously maximizing knowledge and expertise related to Medicare products.

Qualifications

BA/BS with commensurate Compliance industry experience.

10+ years' experience in a Medicare or healthcare Compliance leadership position

Seasoned knowledge and experience within the insurance and financial service industries related to compliance, governance, regulatory, legal strategies.

Seasoned knowledge and understanding of healthcare laws, regulations, and standards, specifically related to Medicare and Medicare Advantage operations.

Thorough understanding of health plan operations, finance, quality, coding and reimbursement systems, risk management, fraud, waste and abuse programs, human resources, and performance metrics.

Experienced in interpretation, implementation and management of HIPAA Privacy and Security Rules.

Extensive knowledge of emerging compliance trends and the ability to identify and assess compliance risks and develop corporate strategies.