Senior Manager, Compliance Program

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. 

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

The Senior Manager, Compliance Program will manage the day-to-day operations of the compliance function of Point32Health’s Government Programs Compliance Program. This includes identifying and having a detailed knowledge of compliance requirements; identifying compliance risks; and direct administration of activities, projects, and personnel necessary to ensure compliance with Medicare, Commercial and Medicaid laws and regulations and governing contracts with the Centers for Medicare and Medicaid Services (CMS) and, as applicable, State Agencies.The Senior Manager, Compliance Program will report to the Government Programs Compliance Officer. This position supporting the Chief Compliance and Ethics Officer and the Government Programs Compliance Officer and working collaboratively as a member of the compliance leadership team.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Provide leadership for execution on a strategy for sustaining compliance with applicable federal and state laws and regulations in the Government Programs Compliance Program that is effective and efficient, including leading people and processes and building a culture of integrity.
• In consultation with the Government Programs Compliance Officer, responsible for managing, documenting, and maintaining a coordinated regulatory compliance infrastructure that meets the expectations of State Medicaid and/or Federal Medicare regulators and corporate governance programs.
• Ensure a high-standing relationship with CMS/EOHHS regulators in support of Point32Health’s government products and meet the expectations and requirements of internal and external customers. Serve as primary liaison between CMS/EOHHS and Point32Health to respond to CMS/EOHHS concerns and to advance Point32Health’s business and regulatory priorities.
• Coordinate external and internal monitoring reviews.
• Develop and implement program policies, procedures and practices designed to promote compliance with the requirements of State and Federal health care programs and that implement components of the compliance program.
• Work autonomously with the Senior Leadership team and department heads to increase awareness of the importance of the Compliance Program and develop and maintain positive relationships between compliance and operations personnel. Attend operations staff meetings for functions with significant impact on compliance.
• Work with the Senior Leadership team and department heads to provide adequate information to ensure that they and their employees have the requisite information and knowledge of regulatory issues and requirements to carry out their responsibilities in a lawful and ethical manner.
• Manage the compliance unit’s administrative duties, including organizing and maintaining relevant documents; preparing necessary reports on activities; and directing and supervising staff, including administering performance evaluations and disciplinary action as needed.
• Monitor compliance performance by operational areas.
• Undertake investigations of compliance inquiries, prepare reports, and monitor remediation.
• Develop external contacts to position the Company as a leader in health care compliance programs.
• Lead annual and ongoing risk assessment processes and develop associated risk assessment reporting;
• Develop and maintain program and procedures for vendor (FDR and Material Subcontractor) oversight.
• With the Audit and Monitoring unit of the Compliance Department, develop audit, monitoring, and compliance work plans and oversee their implementation.
• Monitor and report on the effectiveness of corrective action plans.
• Collaborate with the Fraud