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Years of Experience
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ProfileSenior Manager, Ethics & Compliance Duties: Manage and implement strategies to ensure successful maintenance and implementation of compliance programs that meet regulatory requirements for assigned products across the entire company. Ensure all Medicare and Medicaid product and services are being tested for compliance with program regulations, insurance regulations, and regulatory requirements for business entities. Maintain and track laws and regulations, contract documentations, amendments, and various compliance measures. Develop policies, procedures, and process to comply with federal program regulations, and any applicable state regulations. Provide guidance to various departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contract language. Conduct compliance audits, develop and implement corrective action plans. Perform plan risk assessments and report emerging trends, deficiencies and variances; report findings to other departments and teams as appropriate. Provide required Ethics, Compliance, Risk Management, FWA, privacy, and security training for existing and new employees and as required non-employees. Provide mentoring and guidance to subordinates within the department as necessary. Serve as primary backup to department lead as necessary. Commercial Insurance (additional responsibilities): Monitor Commercial product risks in accordance with the risk reporting policies. Manage Benefit Filings and entity licensures for all products to ensure compliance with state and federal regulatory requirements. Work in collaboration with Marketing teams to monitor Sales & Marketing representatives and materials used in advertisements. Medicare (additional responsibilities): Monitor the FDR oversight program to ensure all Medicare and MMP plans are conducting the appropriate oversight in a timely manner. Report all Medicare and Medicaid product risks in accordance with the risk reporting policies. Partner with various departments as the local executive responsible for ensuring that state and/or federal regulatory requirements relating to business continuity and disaster recovery are communicated and met.
Qualification and Experience
Qualifications: Bachelors’ degree in related field or equivalent experience. Master's or JD Degree preferred. 5+ years of compliance experience, preferably in a healthcare environment with at least 3+ years of Medicaid, Medicare or Commercial Managed Care experience. Previous experience demonstrating effective interaction with federal and state regulatory agencies in a managed care or insurance environment preferred.
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