Job Description

Job Description

Job Description

Description:

Mass Advantage is a Medicare Advantage health plan, located in Worcester, MA. We are affiliated with the largest health care system in Central Massachusetts, UMass Memorial Health. They are the clinical partner of the University of Massachusetts Chan Medical School, with access to the latest technology, research and clinical trials.

We are seeking a Chief Compliance Officer to serve as the primary contact with the Center for Medicare and Medicaid Services (CMS) for Medicare compliance communications. This person is responsible for ensuring overall compliance with all Medicare and regulatory compliance activities and programs. The position will develop and perform trainings for staff on Medicare and regulatory topics and new requirements, as well as manage program requirements such as Health Plan Management System (HPMS) submissions and related activities.

*This position is hybrid (remote/office).

Essential Duties and Responsibilities

• Oversee and monitor all aspects of the implementation of the compliance program, including an annual schedule of compliance activities
• Coordinate and communicate to internal departments and external vendors, where appropriate, all compliance activities and programs as well as plans, implements and monitors the organization’s Medicare compliance program
• Develop and/or maintain a comprehensive Compliance Program for the organization, including response to all compliance questions or concerns
• Develop, revise and present compliance specific training programs for the organization’s employees, sales staff, and first tier, downstream and related vendors
• Develop and update compliance policies and procedures for the organization to ensure compliance with Federal regulations.
• Responsible for organizational compliance with CMS transmittals, HPMS notices, uploading of Medicare applications, bid submissions, submission of sales events and Parts C and D reporting data in HPMS, material review and submission, marketing submission, including code management and track dates and deliverables to ensure that deadlines are met, as well as all CMS audits and produce corrective action plans as necessary
• Ensure compliance with program requirements and regulations governing service area expansions, Plan Benefit Packages (PBP), and maintain HPMS information as appropriate.
• Work collaboratively with internal stakeholders to ensure that internal controls are in place and internal monitoring, auditing and oversight functions are being performed, and that deficiencies are fixed
• Communicate to and work collaboratively on compliance activities with the organization’s Chief Executive Officer
• Prepare regular compliance summaries for the organization’s Chief Executive Officer, leadership team and Board of Directors
• Manage and coordinate external audits, including CMS Financial Audits, Bid Audits, Program Audits, Risk Adjustment Validation Audits, Data Validation Audits and any other CMS ad hoc or targeted audits
• Provide corrective action plans, as appropriate; ensure compliance with Federal laws, rules, regulations, manuals and transmittals pertaining to the operation of the compliance program by working with various Departments to determine the implementation and operational impact of such laws, rules and regulations on the organization
• Serve as Chair in the Corporate Compliance Committee. Meeting occurring no less than quarterly
• Ensure that delegated entities, first tier, downstream entities and independent contractors who furnish services to Mass Advantage members are informed of Mass Advantage’s standards of business conduct with respect to privacy, fraud, waste and abuse, amongst other topics

Other job duties may be assigned from time to time

* Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

• A Bachelor’s degree in Health Care Administration or other related field required; Master’s degree in Health Care Administration, Business Administration, Public Administration, Clinical Area preferred
• A minimum of four years’ experience in a private and/or public sector regulatory agency compliance position is required.
• Five (5) years’ experience with Medicare Managed Care programs is required.
• Knowledge of CMS and Medicare Advantage Prescription Drug Plans and Special Needs Plans and Health Care Compliance Certification is preferred
• Experience with compliance, project management and documentation detail add value to the skill set for this role
• Certified in Healthcare Compliance (CHC) preferred
• Project Management skills, analytic skills, ability to digest and summarize regulatory changes and/or impact

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