Job Details

Vice President Regulatory Compliance

Company name


Organization Type


Job Type


Date Last Verified

Sep 18,2019

Valid Through

Jan 01,2020

Posted on

Jul 19,2019

Years of Experience

Min 15 yrs required


New York City, NY, United States

Employment Type



Practice Area
Health Care >> Health Care
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Vice President, Regulatory Compliance
The candidate will oversees the strategy, design, development, implementation, and evaluation of the EmblemHealth Regulatory Compliance Program that identifies and monitors compliance with Federal and State laws including, but not limited to Medicare Advantage, Medicare Part D, Medicare Special Needs Plans, Medicaid, Medicaid Advantage, and Commercial lines of business (i.e., Essential Plan, Child Health Plus, Medicare Supplement, Health Insurance Exchange products). Presents to the Board of Directors and the Combined Corporate Compliance Committee of the Board of Directors as needed and upon request. Expand the Regulatory Compliance program to include all government programs such as Medicare Advantage, Medicare Part D, Medicare Advantage Special Needs Plans, Medicaid, Medicaid Advantage, CHIP, MLTC, FIDA, and Commercial lines of business, such as the Essential Plan, Medicare Supplement and health insurance exchange products. Maintains a working knowledge of relevant issues, laws and regulations affecting the organization and industry. Works with various outside external entities including, DFS, DOI, DOH, AHIP, and Attorney General on behalf of the enterprise. Plans and performs a comprehensive mock audit program, including an annual Medicare Compliance Program Assessment or other special projects that assist the organization with accomplishing its objectives by evaluating and improving the effectiveness of internal control process(es). Oversees and coordinates of all external audits with the Centers for Medicare and Medicaid Services, Human and Health Services, Office of the Inspector General, and the Department of Health. Collaborates with state Medicaid programs, Medicaid Fraud Control Units, commercial payers, and other organizations when a fraud, waste or abuse issue is discovered to involve multiple parties. Oversees the organization’s Delegate Oversight and Vendor Management programs, including administration of the Delegate Oversight Committee, management of annual delegate audits, facilitation and confirmation of delegate corrective action preparation and implementation, monitoring vendor data reporting, and facilitating vendor corrective action plan preparation and implementation. Directs the identification and evaluation of Enterprise-wide regulatory risk areas through an annual risk assessment process and the development of the annual Compliance Auditing and Monitoring Plan. Responsible for the risk management issues that directly impact the strategic direction of the organization. Charged with delivering the strategy to the company by identifying, evaluating, mitigating and monitoring various risk factors. Reports to Senior Management to advise on all potential risk and exposure to the Plan. Makes significant contributions towards short and long-term business initiatives which include Operating Income, Administrative Expenses, Medicare & Medicaid ratings, and Net Promoter Score performance-Identifies, hires, & trains staff members, developing them into strong leaders and creating high-performing, self-directed teams. Effectively plans for succession planning ensuring talent pipeline. Acts as change agent to drive and effect organizational change ensuring key deliverables are met. Should have Master’s Degree in Healthcare administration, Business, or Related Field) or other Advanced Degrees (Juris Doctor, Medical Doctor). Should have 15+ years of relevant experience. Should have experience working in or with CMS and other government regulatory agencies. Certification in Healthcare Compliance preferred.

Additional info

Requisition ID: 190ET

Company info

Hiring Coordinator
55 Water Street Lobby
New York City, NY 10041-8190

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