Program Manager, Insurance Compliance - Peak Health

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The Program Manager, Insurance Compliance will play a vital role as part of a growing, fast-paced team delivering guidance to business partners and delivering compliance program expertise to support Peak Health products including Medicare Parts C and D, third-party administration, and commercial health plan products. The ideal candidate will understand an effective health plan compliance program, have excellent organizational and analytical skills, have the ability to work independently and effectively research and communicate compliance requirements to various stakeholders within the organization.

The Program Manager, Insurance Compliance will report to the Chief Compliance Officer. The Program Manager is responsible for leading various aspects of the compliance program, including CMS program audit preparation and coordination, employee training, communications and marketing reviews, and being a knowledgeable and trusted compliance partner for business operations. In addition, the Program Manager will assist with oversight activities including risk management, investigations and assessments. The Program Manager is also expected to improve existing processes. This role requires knowledge of Medicare regulations and experience in and health plan operations.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in healthcare administration, business administration, or related field

EXPERIENCE:

1. Four (4) years of health plan compliance or related experience

OR

Two (2) years of experience in health plan operations  

OR

Four (4) years of program management or related experience

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Advanced Degree, or equivalent work experience in lieu of

2. Certified in Healthcare Compliance (CHC) or industry equivalent

EXPERIENCE:

1. Consulting experience in Medicare program compliance.

2. Strong written and oral communication skills, with the ability to communicate complex information at all levels of the organization

3. Experience delivering guidance to business areas related to the Medicare Managed Care Manual

4. Proficient knowledge of Window suite including, Outlook, Sharepoint, Word and Excel. 

5. Proficient knowledge of SmartSheets.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Participate in and support compliance program activities including risk management, auditing, monitoring, investigations, and training.

2. Provide subject matter expertise and program management relating to CMS program audit and Data Validation audit and related activities.

3. Support health plan operations to ensure compliance with applicable rules and regulations, while supporting a positive member experience.

4. Provide analysis, interpretation, training, and education as needed to ensure understanding and effective implementation of compliance requirements.

5. Assist with FDR/Delegated entity activities, including documentation of all pre- and annual delegate oversight and on-going vendor monitoring activities.

6. Review and track CMS communications and marketing reviews; review deliverables for accuracy and facilitate corrections.

7. Investigate issues with effective research, root cause analysis, and gap analysis for effective remediation and corrective action management.

8. Develop and implement process improvement and automation for Compliance Department.

9. Maintain and enhance current knowledge of compliance and best practices through attendance of meetings and seminars, study of reference materials, and updates to compliance rules and regulations. Review newsletters, journals, best practices, updates to compliance rules and regulations, etc.

10. Enhance and drive the maturity of the Peak Health Compliance Plan to deliver optimum customer value and employee engagement.

11. Assist with various projects as assigned.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be