Director, Medicare Compliance

Grand Rapids, MI - USA

Monthly Salary: Not Disclosed

Posted on: 4 hours ago

Vacancies: 1 Vacancy

Job Summary

The Medicare Compliance Officer (MCO) is responsible for the development implementation and oversight of Priority Healths Medicare compliance program. The MCO will report to the Priority Health VP Compliance & Privacy Officer with a dotted-line to the Priority Health VP Medicare. The MCO provides advice and counsel to Priority Health and Corewell Health leaders and departments on compliance matters related to Priority Healths Medicare plans. The MCO serves as the point of contact for Priority Healths CMS regional account manager and serves as the organizations subject matter expert regarding CMS program requirements.

Essential Functions

Responsible for the development management implementation and oversight of the Medicare compliance program. Responsible for the overall direction performance and supervision of the Medicare compliance teams. Assumes accountability for the teams deliverables ensuring the achievement of team goals and objectives in addition to individual goals and objectives.
Assists in and as needed directs complex compliance investigations and works with operational leaders and assigned Compliance team members to determine the appropriate handling of such issues. May work with external regulatory agencies and legal counsel to resolve compliance issues. Serves as the point of contact for Priority Healths CMS regional account manager.
Responsible for monitoring developments related to laws and regulations impacting the Medicare Advantage and Prescription Drug Plan as well as industry trends in Medicare compliance programs. Assists in communicating these developments and responsible for leading the development/modification of policies and procedures to accommodate any legal/regulatory changes and updates. Serves as Corewell Healths subject matter expert regarding CMS program requirements manuals published guidance and rules specific to Medicare managed care.
Leads compliance initiatives and communication of ongoing compliance efforts risk identification audit results and mitigation efforts to further awareness and effectiveness of the Medicare compliance program. Performs ongoing Medicare compliance risk assessments as a part of the overall enterprise risk management program. Develops and implements the Medicare compliance work plan.
Presents to various compliance committees executive leadership meetings and other meetings as requested on compliance initiatives audit results and corrective action plans including the Priority Health Board of Directors. Serves as a member of Priority Healths Compliance Committee and chair of the Medicare Compliance Subcommittee as well as leads and participates in associated Medicare compliance subcommittees and internal meetings.
Collaborates with operational leaders and teams at Priority Health and Corewell Health to change and improve business processes to support and mitigate risks to the organization and patient/member rights. Collaborates closely with other key internal stakeholders including medical pharmacy risk adjustment quality legal internal audit and finance departments leaders and team members.
Responsible for coordination planning and participation in any CMS operational financial or other audits.
Mentors coaches and develops direct reports and acts as a role model and resource. Holds staff accountable for high performance against job descriptions policies & procedures controls and processes as well as organizational standards and policies. Completes performance reviews recommends and initiates personnel actions such as interviewing hiring performance correction and terminations.

Qualifications

Required

Bachelors Degree in law business health care operations/management information technology/information security nursing or other clinical area
5 years of relevant experience in health care compliance and/or clinical or operational leadership experience.

Preferred

3 years of relevant experience in managed care setting
3 years of relevant experience in Medicare managed care compliance
Health plan andgovernment programsexperience
People management experience
CRT-Healthcare Compliance Certified (CHC) - HCCA Health Care Compliance Association

Physical Demands

Pallet to Waist (6 from floor) > 5 lbs: Seldom up to 10 lbs
Waist to Waist > 5 lbs: Seldom up to 10 lbs
Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
Waist to Overhead > 5 lbs: Seldom up to 10 lbs
Bilateral Carry > 5 lbs: Seldom up to 10 lbs
Unilateral Carry > 5 lbs: Seldom up to 10 lbs
Pushing Force > 5 lbs: Seldom up to 10 lbs
Pulling Force > 5 lbs: Seldom up to 10 lbs
Sitting: Frequently
Standing: Occasionally
Walking: Occasionally
Forward Bend - Standing: Seldom
Forward Bend - Sitting: Occasionally
Trunk Rotation - Standing: Seldom
Trunk Rotation - Sitting: Occasionally
Reach - Above Shoulder: Seldom
Reach - at Shoulder or Below: Seldom
Handling: Occasionally
Forceful Grip > 5 lbs: Seldom
Forceful Pinch > 2 lbs: Seldom
Finger/Hand Dexterity: Frequently

How Corewell Health cares for you

Comprehensive benefits package to meet your financial health and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you like restaurants phone plans spas and more!
Optional identity theft protection home and auto insurance pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids

Department Name

System Compliance - Corporate

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

Hours of Work

8 a.m. to 5 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

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Corewell Health is committed to providing a safe environment for our team members patients visitors and community. We require a drug-free workplace and require team members to comply with the MMR Varicella Tdap and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process to perform the essential functions of a job or to enjoy equal benefits and privileges of employment due to a disability pregnancy or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race color national origin sex disability age religion genetic information marital status height weight gender pregnancy sexual orientation gender identity or expression veteran status or any other legally protected category.

An interconnected collaborative culture where all are encouraged to bring their whole selves to work is vital to the health of our organization. As a health system we advocate for equity as we care for our patients our communities and each other. From workshops that develop cultural intelligence to our inclusion resource groups for people to find community and empowerment at work we are dedicated to ongoing resources that advance our values of diversity equity and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.

Required Experience:

Director

Job SummaryThe Medicare Compliance Officer (MCO) is responsible for the development implementation and oversight of Priority Healths Medicare compliance program. The MCO will report to the Priority Health VP Compliance & Privacy Officer with a dotted-line to the Priority Health VP Medicare. The MCO ...