Senior Manager, Compliance

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

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

Job Summary

The Compliance Senior Manager will report to the Government Programs Compliance Officer. This position includes supporting the Chief Compliance and Ethics Officer and the Government Programs Compliance Officer and working collaboratively as a member of the compliance leadership team.

Key Responsibilities/Duties – what you will be doing

Role Overview: Lead the execution of a strategic plan to ensure compliance with federal and state laws and regulations related to the Government Programs Compliance Programs for Medicare and Duals products. This role involves guiding teams and processes while fostering a culture of integrity.

Key Responsibilities:

• Leadership & Strategy: Develop and implement effective compliance strategies, ensuring adherence to Federal Medicare and State requires related to Medicare Advantage and Prescription Drug Plans and Dual Programs (SCO and One-Care).
• Regulatory Compliance: Manage and maintain a robust regulatory compliance infrastructure that aligns with corporate governance programs.
• Stakeholder Relations: Maintain strong relationships with CMS/EOHHS regulators, serving as the primary liaison to address concerns and advance business and regulatory priorities.
• Policy Development: Create and enforce policies, procedures, and practices to ensure compliance with healthcare program requirements.
• Collaboration: At the direction of the Medicare Compliance Officer, collaborate with leadership and department heads to promote compliance awareness and foster positive relationships between compliance and operations teams.
• Information Dissemination: Ensure that leadership and employees are well-informed about regulatory issues and requirements.
• Administrative Management: Oversee the compliance unit’s administrative tasks, including document organization, report preparation, and staff supervision.
• Performance Monitoring: Track compliance performance across operational areas.
• Investigations & Reporting: Conduct compliance investigations, prepare reports, and monitor remediation efforts.
• Risk Assessment: Support the implementation and maintenance of a coordinated risk assessment process.
• Vendor Oversight: Support the development and maintenance of oversight programs for vendors (FDRs and Material Subcontractors).
• Audit & Monitoring: Support Audit and Monitoring unit to develop and implement compliance work plans.
• Corrective Actions: Monitor and report on the effectiveness of corrective action plans.
• Fraud Prevention: Work with the Fraud Special Investigations Unit to ensure compliance with CMS requirements.
• Reporting: Provide updates and reporting to the Government Programs Compliance Officer to support the Compliance Committee and other meetings as needed. 
• Monitoring & Reviews: Support the coordination of both external and internal compliance reviews.

This role requires a proactive leader who can work autonomously, communicate effectively, and build strong relationships to ensure the success of the compliance program.

Qualifications – what you need to perform the job

EDUCATION: Bachelors Degree

EXPERIENCE: 

Minimum of 5-7 years of directly related experience (5+ years of Medicare and/or Medicaid Compliance experience) in personnel management and compliance related activities, legislative and regulatory activities, health insurance operations or legal research or equivalent combination of education and experience.

Strong experience with Medicare and/or Medicaid health care products is required.  Demonstrated knowledge of government regulations as they relate to th