The purpose of the position is to manage the day-to-day operations of the compliance function of Tufts Health Plan’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 and Medicaid laws and regulations and governing contracts with the Centers for Medicare and Medicaid Services (CMS) and, as applicable, State Agencies.
The Compliance Senior Manager will report to the Government Programs Compliance Officer. This 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.
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. This includes leading people and processes and building a culture of integrity.
Sole responsibility 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 Tufts Health Plan’s government products and meet the expectations and requirements of internal and external customers. Serve as primary liaison between CMS/EOHHS and Tufts Health to respond to CMS/EOHHS concerns and to advance Tufts Health Plan’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 autonomously 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. This includes 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.
Implement and maintain risk assessment process coordinated.
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 special investigations unit to ensure program meets CMS requirements.
Provide updates and reports to Compliance Steering Committee as needed.
Participate as a member of the compliance leadership group.
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 the administration of Medicare and/or Medicaid healthcare programs, principles and practices of managed care. Project coordination and management experience.
Ability to influence others at all levels across the organization without direct reporting authority
Strong research, writing, public speaking and computer skills
Understanding of health policy issues related to medical and other healthcare activities.
Strong subject matter expertise in Medicare and/or Medicaid Operations and Compliance Requirements
Demonstrated effectiveness operating in complex organizational environments.
Excellent written, oral, and presentation communication skills.
Proven ability to work with all levels of management.
Strong problem-solving skills.
Demonstrated ability to partner effectively with others in the handling complex issues
Strong leadership skills with ability to lead cross functional teams
Ability to develop and support staff in their professional development
Sense of Humor
WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel,) CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Will be exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy and department guidelines/policies and all applicable laws and regulations at all times.
What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!
A nonprofit organization founded in 1979, Tufts Health Plan is nationally recognized for its commitment to providing innovative, high-quality health care coverage. We strive to improve the health and wellness of the diverse communities we serve. Our employees are hard-working, innovative, and collaborative. They look for opportunities to grow and make a difference, and they help make us one of the Top Places to work in the area.