Director, Contract Compliance

About the role

This role will focus on pharmacy benefit compliance regarding state and federal requirements. In addition, this role will support internal oversight of the department regarding URAC and NCQA requirements. Responsible for assessing major business opportunities and potential business partners and corresponding to compliance issues. Manages and coordinates all in-state and out-of-state corporate and contractual requirements and policy form filings as they relate to regulatory compliance in all operating states and the District of Columbia. Manages policy/certificate issuance software. Supervises agent licensing and appointment functions, complaint handling, Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security, and Employment Retirement and Insurance Security Act (ERISA) compliance.

Responsibilities

• Develops solutions and plans of action for major business opportunities.
• Assesses and evaluates potential business partners.
• Designs and implements Privacy and Security compliance programs.
• Assists management in developing policies and procedures consistent with federal and state requirements and implementing necessary changes.
• Directs the implementation of the Patriot Act compliance initiative.
• Ensures all claimants receiving claim checks have been screened against the list of Prohibited Persons published by the Office of Foreign Asset Control.
• Oversees Anti-Money Laundering initiative.
• Ensures that high-risk products and distribution channels receive an increased level of Anti-Money Laundering scrutiny.
• Directs the preparation and approval of all contract language for agency contracts, endorsements, certificates and booklets in all jurisdictions in which agency is authorized to do business.
• Coordinates the development of agency benefits with Senior Management and external personnel.
• Initiates revisions to existing and renewal contracts, certificates, and booklets in all operating jurisdictions to comply with changes in agency operations and to improve clarity and intent of the documents.
• Coordinates and directs the drafting of all policy and certificate language for the company’s product portfolio.
• Implements all policy and certificate revisions and coordinates the review with all appropriate areas.
• Distributes and disseminates changes in contracts to Senior Management and Directors of all business units.
• Directs the filing of all contract language with the Insurance Commissioners in all jurisdictions where agencies operate.
• Obtains approval of all agencies’ policies, certificates, applications, and actuarial information necessary to conduct the business of insurance.
• Gains admission into new states where the company wishes to do business, coordinating activities with Executive Management, Senior Staff, and the Legal Department as appropriate.
• Responsible for the policy and certificate issue system. Writes and oversees the writing of programming logic to ensure the correct language/benefits are issued depending on state of issuance, benefits requested type of policy, and line of business.
• Maintains advertising files in accordance with state advertising regulations.
• Directs Agent Licensing Department. Ensures all producers are appropriately licensed and appointed to represent agency and have current contracts including the requisite HIPAA Business Associate Agreement.
• Reviews incoming memoranda, bulletins, etc. from State Insurance Departments and federal government to determine company position and response.

Requirements

• Bachelor's in a job-related field
• 10 years claims, customer service, appeals, compliance administration or health insurance industry related experience.
• 3 years demonstrated leadership experience in a supervisory/management role or equivalent military experience in grade E4 or above (may be concurrent).
• Familiarity with audit or compliance procedures and regulations.
• Strong customer service orientation.
• Ability to effectively communicate both verbally and in writing to all levels throughout the organization.
• Excellent analytical, critical thinking and problem-solving capabilities.
• Ability to work in a highly changing environment; ability to persuade, negotiate or influence.
• Exercises confidentiality and discretion.
• Excellent presentation skills with a strong attention to detail.
• Ability to interpret and implement complex and ambiguous government rules.
• Microsoft Office proficiency.

Preferred qualifications

• Experience with pharmacy benefit compliance.
• Knowledge of state and federal healthcare regulations.
• Familiarity with URAC or NCQA accreditation standards.
• Experience supporting compliance audits, reviews, or oversight activities.

Benefits

• Subsidized health plans, dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

Schedule & location

Full-time position (Monday through Friday, 40 hours per week) on a hybrid work schedule: three days onsite and two days work at home. Located at 4101 Percival Road, Columbia, SC 29229. Benefits eligibility begins the first of the month following 28 days of employment.