Director, Operational Compliance and Audit

Role Description

Who we are:

UST HealthProof is a dynamic company with a mission to lower the cost of care and deliver the future of healthcare. Our consumer-centric approach gives our health plan customers a modern infrastructure and reduced administrative costs, helping to drive better business results for our customers — and better outcomes for our communities.

We achieve this mission together through teamwork, communication, collaboration, and focus. Our employees are our greatest assets, and we invite you to apply to be a part of our journey toward making a difference in healthcare in the United States.

You Are

As a Director of Operational Compliance and Audit, under the direction of the Chief Compliance Officer, you will oversee and maintain Company compliance with contractual and regulatory obligations and all state and federal requirements related to health insurance and managed care. The Director, of Operational Compliance and Audit will represent the Compliance department, build, and manage strategic partnerships with internal business units and external clients, toward a common goal of compliance excellence. The Director of Operational Compliance and Audit serves as primary support to the Chief Compliance Officer for operational compliance, implementing and leading an effective Compliance Program, ensuring ongoing oversight of compliance-related activities associated with Advantasure’s product offerings. Furthermore, the Director of Operational Compliance and Audit will ensure the company maintains positive relationships with both internal and external stakeholders.

The Opportunity

• Oversee and manage an operational compliance function by working collaboratively with functional areas throughout the organization.
• Implementation and ongoing management of the compliance monitoring strategy (internal, downstream entities, and Medicare Advantage/ Part D Sponsor clients)
• Lead and direct the compliance monitoring strategy, including but not limited to, developing monitoring tools, performing sample-based reviews, compiling/ evaluating key performance metrics, educating stakeholders on regulatory requirements, etc.
• Lead and direct the internal compliance audit and corrective action strategy, including but not limited to, developing audit tools, performing focused audits, compiling findings, educating stakeholders on regulatory requirements, and ensuring corrective actions were implemented timely.
• Facilitate and manage all external audits and corrective action plans, including but not limited to, CMS Program Audits, Data Validation Audits, One-Third Financial Audits, Risk Adjustment Data Validation Audits, and client-specific audits.
• Ensure conclusions, findings, and recommendations for improvement or corrective action are appropriately presented to management staff for review, and verify that all findings are accurate, complete, and objective.
• Conduct an extensive and thorough analysis of regulatory guidance from various sources such as Medicare Managed Care Manuals, Prescription Drug Benefit Manuals, HPMS memorandums, CMS Transmittals, Federal Register publications, etc.
• Provide expertise and guidance to team members and the organization.
• Actively participates in the identification of potential Compliance risks for consideration in the department’s annual Risk Assessment process.
• Oversee the management and timely resolution of consumer complaints, ensuring proper tracking, investigation, and corrective actions are taken as needed.
• Conduct high-quality compliance audits aligned with Medicare rules and regulations.
• Provide timely support and resolution of CTMs and document all actions taken in HPMS in accordance with the CTM Standard Operating Procedures (SOP).
• Establish and maintain a robust Medicare compliance reporting framework, ensuring accurate and timely submission of required data to clients for submission to CMS and other regulatory bodies.
• Lead/coordinate compliance committee and review sessions.
• Manage the incident/inquiry Triage tracking process
• Manage a team of compliance professionals who ensure effective compliance oversight of various compliance departmental processes, including operational compliance.
• Serve as a business partner/consultant with operational areas and assist in maintaining an understanding of and compliance with regulatory requirements and the organization’s internal policies and procedures.
• Function as the liaison with Medicare Advantage/ Part D Sponsor clients, reporting out on operational compliance-related concerns, risks, processes, performance, etc.
• Coordinate with stakeholders to compile and submit reporting data to clients for Medicare Part C & D Plan Reporting and the annual Data Validation Audits
• Facilitate Compliance Governance calls with clients.
• Proactively identify process gaps, weaknesses, deficiencies, or business productivity/efficiency opportunities.
• Report regularly to the Chief Compliance Officer, the Compliance Committee, Executive Leadership, and other governance meetings/ committees on the progress of implementation and operation of the Compliance Program, including but not limited to, key performance indicators, monitoring/auditing issues, corrective actions, government agency activities, and other issues deemed appropriate for executive leadership attention.
• Coordinate with senior management, as well as internal/ external stakeholders, to address issues of potential/ actual non-compliance, FWA, privacy violations, or areas of risk.
• Conduct reviews of all communications and marketing materials to ensure adherence with the Medicare Communications and Marketing Guidelines.
• Manage and coordinate interactions with internal stakeholders, downstream entities, clients, and regulatory agencies, including responding to and documenting responses to all requests.
• Provide support to operational areas when necessary as it pertains to a multifaceted educational and training program that focuses on operational compliance, ensuring all appropriate employees and management know and comply with pertinent federal program requirements related to their functional responsibilities.
• Investigating, in conjunction with counsel as appropriate, and acting on matters related to compliance/ FWA/privacy, including the flexibility to design and coordinate internal investigations (e.g., responding to reports of problems or suspected violations) and any resulting corrective actions (e.g., making necessary improvements to the organization’s policies and procedures, taking appropriate disciplinary action, etc.).
  
  

What You Need

Ten (10) + years of experience in a Medicare Advantage/ Medicare Part D environment, including experience in the areas of Medicare operations and compliance oversight.

• Prior experience managing staff is required
• Highly preferred combined experience of Medicare Compliance, Medicare Product, and Medicare Part C and D Operations (e.g., enrollment, marketing communications, premium billing, appeals and grievances, claims, utilization management, quality, customer service, STARs, and risk adjustment.
• Ability to generate original thoughts and ideas while also being aware of the needs and perspectives of others and maintaining confidentiality.
• Must be highly organized, analytical, and detail-oriented.
• Must be an effective public speaker, presenter, and communicator with diplomacy and tact.
• Strong oral and written communication skills.
• Strong facilitation, collaboration, and teamwork skills with the ability to build cross-functional partnerships to drive results.
• Must be able to facilitate meetings and achieve consensus regarding work plans and responsibilities.
• Demonstrate ability to understand and interpret complex regulations.
• Proficient in Microsoft products and other PC-based applications such as Excel, PowerPoint, and Word.
• Excellent time management skills. Strong conflict resolution skills. Process and project management ability.
  
  

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by applicable law, UST provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role Location: Remote

Compensation Range: $128,000 - 168,000

What We Believe

We’re proud to embrace the same values that have shaped UST HealthProof since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone, to champion diversity and inclusion, and to place people at the center of everything we do.

Humility

We will listen, learn, be empathetic and help selflessly in our interactions with everyone.

Humanity

Through business, we will better the lives of those less fortunate than ourselves.

Integrity

We honor our commitments and act with responsibility in all our relationships.

Equal Employment Opportunity Statement

UST HealthProof is an Equal Opportunity Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

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