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Medicare Compliance Officer and Manager


Posted: 10/2/2019
Job Reference #: 5000496057106

Job Description

Employment Type


Exempt or Non-Exempt


Job Summary

The Medicare Compliance Officer and Manager is responsible for the Medicare Compliance Program that incorporates the following core elements required by the Centers for Medicare and Medicaid Services (CMS) and includes measures to prevent, detect, and correct Medicare noncompliance and fraud, waste, and abuse (FWA).

  1. Written policies, procedures, and Standards of Conduct
  2. Compliance Officer, Compliance Committee, and high level oversight
  3. Effective training and education
  4. Effective lines of communication
  5. Well publicized disciplinary standards
  6. Effective system for routine monitoring and identification of compliance risks
  7. Procedures and system for prompt response to compliance issues

 As many of the core requirements are also incorporated in HMSA's Corporate Compliance and Ethics program, the Medicare Compliance Officer and Manager will coordinate implementation and execution of the Medicare Compliance Program with the HMSA Compliance and Ethics Officer (C&E Officer) and the Compliance and Ethics Manager (C&E Manager).

The Medicare Compliance Officer and Manager also leads staff who are responsible for essential duties and functions that support the successful accomplishment of the Compliance and Ethics Program and the Compliance Program for Government Contracts core requirements.

Minimum Qualifications

  1. Bachelor's (BA) degree with 5 years of related work experience; or an equivalent combination of education and related work experience.
  2. Experience dealing in a regulated environment involving compliance with federal state and local laws and regulations.
  3. Familiarity with general compliance and ethics issues.
  4. Strong analytical skills.
  5. Strong listening and presentation skills.
  6. Strong verbal and written communication skills.
  7. Working knowledge of risk assessment.
  8. Proficiency in Microsoft Office applications. 

Duties and Responsibilities

  1. Execute Compliance and Ethics Monitoring Program and perform reviews to monitor compliance with federal and state regulations, government program rules and sub-regulatory guidance and internal policies and standards.
    • Research and analyze the related regulatory and sub-regulatory guidance and policies.
    • Identify root causes of non-compliance, deficiency, or other irregularity.
    • Report on findings and observations, and corrective action plans.
    • Recommend improvements of varying complexities to strengthen operations in meeting compliance standards.
    • Maintain benchmarks and regularly report results to management and senior management in an accurate and timely manner.
    • Conduct timely follow-up reviews to validate adherence to remediation plans where deficiencies have been identified to promote ongoing compliance.
    • Monitor and review reports, examinations or other documentation to for continued compliance.
  2. Lead the establishment of a system for maintaining necessary documentation related to compliance monitoring activities. Provide the department leadership with regular status reports on compliance monitoring activities.
  3. Lead the development of the Annual Work Plan by identifying compliance risks across the organization. In consultation with department leadership lead the coordination and implementation of the risk assessment plan.
  4. Analyze compliance related literature and maintain requisite knowledge of the current regulatory environment through regular participation in conferences, seminars, and meetings to identify areas of risk and to the organization.
  5. Mentor and coach the Compliance staff and provide guidance on the execution of the Monitoring Program. Continually assess internal processes and identify best practices to enhance effectiveness of the Monitoring Program.
  6. Promote ongoing compliance and overall organizational "audit readiness." Create and foster working relationships with subject matter experts and department leadership to develop actionable plans for their departments to implement best practices and strengthen compliance. Track and trend issues to proactively identify performance improvement opportunities. Effectively communicate objectives with senior leadership to obtain buy-in in aligning performance expectations to audit standards. Develop reports and presentations for management as needed.
  7. Other duties/functions:
    • Maintain satisfactory interpersonal relationships with Compliance and Ethics staff and executive management. Collaborate and coordinate with other staff within the department and throughout HMSA in accomplishing the job responsibilities; be a team player and serve as a role model for others in the organization by always exhibiting courtesy, caring, helpfulness, and respect; be attentive, cooperative, kind, pleasant, respectful, and sensitive when dealing with members, visitors, the public, and other employees. 
    • Address any other areas deemed necessary to ensure the effective operation of HMSA's Compliance and Ethics Program.
    • Perform other duties and responsibilities as assigned by the Compliance and Ethics Manager or Compliance and Ethics Officer.