Medicare Compliance Manager

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

• Integrity

• Accountability

• Collaboration

• Trust

• Respect

Disclaimers:

• Flexible work schedule is based on job duties, department, organization, or business need.

• Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Medicare Compliance Manager reports directly to the Senior Director, Compliance and is responsible for developing, administering and overseeing the Medicare Compliance Program and initiatives in alignment with overall D-SNP strategy as set by the D-SNP leadership. This role will manage and implement compliance projects and program activities focusing on integrating regulatory requirements, industry standards, and organizational policies for Medicare, Medi-Cal, and Knox Keene. Support the oversight and management of the compliance program, implemented to ensure that Gold Coast Health (GCHP) and its first-tier, downstream and related entities (FDRs) consistently operate in accordance with all applicable federal and state laws, regulations, and regulatory guidance.

The Medicare Compliance Manager will possess a deep knowledge of Medicare regulations, strong leadership skills, and a commitment to promoting a culture of compliance throughout the organization.

Duties may also include additional compliance activities assigned by the Chief Compliance Officer or Privacy Officer.

Amount of Travel Required: 10%

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

• Develop, implement, integrate, and manage the Medicare compliance program for D-SNP line of business, ensuring it aligns with regulatory requirements and industry best practices. Ensure integration of the Medicare compliance program with GCHP’s existing compliance program and alignment with overall D-SNP strategy as set by the D-SNP leadership.

• Provide guidance and leadership to cross-functional teams involved in Medicare, Medi-Cal, and Knox Keene compliance activities.

• Collaborate with the Government Affairs Department to maintain compliance with CMS, DHCS, and DMHC requirements, including GCHP’s Knox Keene license and contractual obligations with regulatory agencies.

• Collaborate with the Compliance Department, Operations Oversight Department, D-SNP leadership and other internal stakeholders to address compliance issues, develop corrective action plans (CAPs), and monitor progress towards resolution.

• Responsible for daily monitoring of CMS’s Health Plan Management System (HPMS), required DHCS reporting, DMHC filings, and other required regulatory submissions.

• Work with the Sr, Director, Compliance, Government Affairs Department, and D-SNP leadership, in the creation, maintenance and implementation of HPMS memos, policies, procedures and compliance documents.

• Ensure that communication of Medicare regulatory information is clear and concise and disseminated. Ensure that responsible parties are implementing solutions to support internal and external operational compliance.

• Consult on investigations for any incoming Medicare Part C and D compliance complaints of potential non-compliance, including collaborating with SIU regarding potential Fraud, Waste and Abuse, as needed.

• Maintain proficiency of changes in Medicare Part C and D, Medi-Cal, and Knox Keene regulations, guidance, and enforcement priorities as it pertains to MMP/D-SNP line of business.

• Support the development and implementation of compliance training and educational materials on Medicare, Medi-Cal, and Knox Keene.

• Participate in Medicare compliance-related committees, working groups, and initiatives to promote a culture of integrity, ethics, and compliance.

• Work with Compliance team to create and maintain an effective Medicare compliance program, including processes for the review, analysis and stratification of compliance risks and issues.

• Provide routine updates regarding compliance performance concerns and risks to the Sr, Director, Compliance and D-SNP leadership, including supporting technical and analytical information as needed.

• Support external audits, and educate internal business partners, vendors and delegates on Medicare requirements in preparation for audits, data reporting, and data validation activities to ensure the best possible outcomes.

• Collaborate with Human Resources and Compliance Program Manager to ensure that covered persons are checked against the Office of Inspector General (OIG) exclusion lists and General Services Administration (GSA) debarment lists monthly and FDR attestation/certifications are signed.

MINIMUM QUALIFICATIONS

Education & Experience:

Required Education and Experience:

• Bachelor's degree in Healthcare Administration, Business Administration, or in a related field

• Minimum of 5 years of experience in healthcare compliance, with a focus on Medicare compliance and regulations.

• Medicare part C and D expertise, including demonstrable knowledge of Medicare regulations, guidelines, audit protocols and processes.

Preferred Education and Experience:

• Master's degree in Healthcare Administration, Business Administration, or in a related field

• Prior experience with CMS audits (program, timeliness, and data validation) as well as DHCS and DMHC compliance requirements.

• Broad and detailed knowledge of health plan operations and best practices.

• Experience with Corporate Integrity Agreements.

• 3 years of experience in program management or project management

• Equivalent In lieu of degree: Will accept experience in any combination of academic education, professional training, or work experience, which demonstrates the ability to perform the duties of the position.

• 9 years of healthcare compliance experience, with a minimum of 6 years in the Medicare compliance space.

KNOWLEDGE, SKILLS & ABILITIES

Preferred Qualifications:

• Ability to establish, nurture and maintain strong and effective working relationships with GCHP staff, governmental and regulatory staff, legal counsel, and others.

• Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes.

• Ability to assume responsibility and exercise good judgment with making decisions within the scope of the position.

• Technology & Software Skills: Advanced computer skills in MS Office products.

• Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

• Healthcare compliance certification: Certification in Healthcare Compliance (CHC), Certified in Healthcare Privacy and Compliance (CHPC) or will obtain certification within 18 months of employment.

Competency Statements

• Management Skills - Ability to organize and direct oneself and effectively supervise others.

• Business Acumen - Ability to grasp and understand business concepts and issues.

• Decision Making - Ability to make critical decisions while following company procedures.

• Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.

• Interpersonal - Ability to get along well with a variety of personalities and individuals.

• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

• Consensus Building - Ability to bring about group solidarity to achieve a goal.

• Relationship Building - Ability to effectively build relationships with customers and co-workers.

• Presentation Skills - Ability to effectively present information publicly.

• Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.

• Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.

• Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.

• Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.

• Judgment - The ability to formulate a sound decision using the available information.

• Communication, Oral - Ability to communicate effectively with others using the spoken word.

• Communication, Written - Ability to communicate in writing clearly and concisely.

• Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.