Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. The Manager, Medicare Compliance, will assist the Medicare Compliance Officer (MCO) in ensuring Martin’s Point (MP) Medicare Advantage (MA) products, service offerings and internal technology for the Generations Advantage (GA) plan and its contracted vendors are fully compliant with Centers for Medicare and Medicaid Services (CMS), the State regulations and licensure requirements in the states in which it operates and all other applicable Federal regulations.
Under the direction of the Medicare Compliance Officer, the position will support the oversight and management of the Medicare compliance program by:
- Providing leadership and team development to the Medicare compliance team, including identification of training opportunities to promote growth of industry or organizational knowledge, role development and/or stretch assignment opportunities
- Maintaining proficiency with Medicare Part C and Part D regulations, Medicare Managed Care Manuals, sub-regulatory guidance and knowledge of health plan operations
- Working with the MCO to create and maintain an effective Medicare compliance plan including processes for the review, analysis and stratification of compliance risks and issues
- Maintain effective business relations with CMS regulators, third-party regulators and business partners, vendors and delegates
- Provide routine updates regarding compliance performance, concerns and risks to the MCO, or other leadership as appropriate, including supporting technical and analytical information as needed
- Develop and oversee a team of Medicare SMEs integral in the delivery of a regulatory compliance education plan to be delivered to MP employees; an established audit plan and process which monitors compliance risk areas within the Medicare program, and amend the audit schedule as risk issues are identified and an investigation and remediation process that includes collaboration with operational business departments, to ensure prompt response to an investigation of any action inconsistent with applicable Medicare regulatory requirement
- Assist the Medicare Compliance Officer in the creation, maintenance and implementation of policies, procedures and compliance documents
- Support and/or lead internal and external audits
- Fraud, Waste and Abuse (FWA) – Provide oversight and direction for staff involved in investigating FWA allegations received via the hotline and other reporting mechanisms. Ensures outreach to applicable parties (enrollees, providers, etc.) to obtain additional information and/or provide resolution and root cause analysis to identify opportunities for improvements and work with cross-functional teams as applicable
- Serve as the back-up liaison for CMS and/or other regulatory inquiries
- Prepare internal business partners, vendors and delegates for CMS audits to ensure the best possible outcomes
- Ensure completion of deliverables within required timeframes
- Bachelor’s degree required or equivalent combination of education and work experience in a relevant field
- Medicare Part C and D expertise required, including 5 years of leadership experience in MA or Part D operational area or related field
- Demonstrable knowledge of Medicare guidelines, audit protocols and processes required
- Demonstrable ability to convey complex information in a meaningful way to a variety of audiences required
- Prior experience with CMS full program, and/or other audits preferred
- Broad and detailed knowledge of Medicare Part C and D health plan operations and best practices preferred
- Previous Compliance, Integrity, FWA or directly related experience preferred
- Ability to translate regulatory requirements to business and/or technical system requirements
- Excellent interpersonal, verbal and written communication skills
- Strong project management skills
- Approaches work assignments in an organized, process-focused manner, which fosters the achievement of effective results
- Critical thinking: can identify root causes and implement creative solutions
- Ability to prioritize time and tasks efficiently and effectively for self and others
- Ability to prioritize and manage multiple competing demands
- Ability to function independently
- Strong management and leadership skills; ability to prioritize time and tasks efficiently and effectively for self and others, manage multiple competing demands
- Proficient user of Microsoft Office Applications (e.g. Word, Excel, Visio, Project, PowerPoint, and Access)
- Ability to move between MP sites
- CRT use for 75% of work day
- Ability to sustain sedentary activities for prolonged periods of time.
- Ability to work at a computer station and perform administrative type functions.
- Ability to perform all essential functions of the job with or without reasonable accommodations.
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at: firstname.lastname@example.org