Lead Director, Medicaid Compliance External Audits – Texas

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Position Summary:

As a Lead Director of Medicaid Compliance and External Audits, you are in a senior level compliance position responsible for the management, execution, and oversight of a high volume of external audits, ad hoc state requests and inquiries, and associated internal and external CAPs for a highly complex Medicaid managed care market.  In this role you oversee the activities of other compliance team members assigned to the market and maintains matrices responsibility for managing and reviewing state deliverables prepared by shared service partners and business leads from across Aetna Medicaid. You are primarily responsible for developing and maintaining systems and processes to manage the health plan’s preparation, response, and successful completion of a high volume of complex external regulatory audits, ad hoc state inquiries and escalated state issues or requests.

Responsibilities include, but are not limited to:

• Serving as the principal liaison to the state Medicaid agency for all external audits and escalated state matters, ensuring effective compliance and contract-related communication and activities within a highly regulated and complex Medicaid health plan.

• Facilitating the preparation for and management of external audits conducted by state Medicaid and related agencies or partners through final report and corrective action plan closure

• Supervising the submission of all audit deliverables and ad hoc state requests or escalated issues, ensuring that strategic and quality reviews are conducted prior to submission to address compliance-related concerns, appropriate escalations are made to executive leaders for deliverables that fail to meet all requirements, and collaborate with health plan counsel to facilitate appropriate legal review

• Conducting comprehensive lessons learned evaluations following post-audit and develop proactive corrective actions with executive leaders to address identified deficiencies prior to issuance of the final report.

• Conducting research and develop recommendations to help executive leadership across Aetna Medicaid develop compliant business operations, processes and policies in accordance with state specific Medicaid program requirements

• Independently developing compelling, strategic, and appropriate compliance related communications on behalf of the health plan in response to state Medicaid agency audit-related inquiries or requests and escalated state issues

• Maintaining an in-depth working knowledge of the health plan’s contractual, regulatory, and program policy related obligations as a Medicaid managed care organization and serve as a resource to health plan and growth partner staff through the preparation, submission, and response to external audits, ad hoc inquiries, and escalated state requests.

• Designing and managing tools for tracking and handling complex state external audits and escalated issues, including deliverable assignments, deadlines, internal reporting and summaries, risk monitoring, and analyses of findings; Ensure these resources are user-friendly and accessible to business partners to support effective and efficient audit preparation and completion.

• Utilizing systems unique to job functions, including standard-issue software such as Microsoft products and compliance specific tools such as Archer or QuickBase

• Maintaining positive, productive relationships with internal and external senior level constituents to effectively communicate and influence ethical and compliant outcomes

• Providing training and guidance to less experienced team members to accomplish goals

• Other duties as assigned

Required Qualifications:

• 10 years previous experience in Medicaid or Medicaid managed care

• 2+ years previous experience managing external audits

• 2+ previous management experience

• 5+ years regulatory compliance position in managed care, health care, or insurance or 3 years with Master’s Degree

• Ability to travel (up to 25% - including plane) to Texas for audit preparations and on-site reviews

• Regular and reliable attendance due to time sensitive nature of external deliverables and activities

Preferred Qualifications:

• Pr