Director, Legal, Regulatory Affairs, and Compliance

About the role

The Director, LRAC serves as Mass General Brigham Health Plan’s Government Programs Compliance Officer and plays a crucial role in managing an effective compliance program for the Medicaid, Medicare Advantage (MA), One Care and Senior Care Options lines of business.

Responsibilities

• Develop and implement the annual Medicaid, Medicare Advantage, and Duals Compliance Program (Government Programs Compliance Program) and workplans, ensuring compliance with regulatory requirements, optimizing plan compliance performance, and coordinating with various teams to enhance the overall quality of care and member satisfaction.
• Implement and lead external auditing and internal monitoring activities of the Government Programs Compliance Program, including CMS and EOHHS audits as well as the monitoring and auditing of vendors. Ensure engagements are completed objectively, professionally, and in accordance with industry audit standards.
• Manage and report an annual evaluation on the Government Programs Compliance Program and present to the Executive Committee and Board of Directors.
• Work collaboratively with department heads to develop, update, and enforce policies and procedures to ensure compliance with legal and regulatory requirements.
• Identify and assess areas of compliance risk for the organization and work with the business to develop corrective action plans.
• Develop and/or ensure internal controls are capable of preventing and detecting significant instances or patterns of illegal, unethical, or improper conduct.
• Complies with all policies and procedures
• Perform other duties as assigned

Qualifications

• Education: Bachelor's required; Master's degree preferred
• Experience: At least 8-10 years of Medicare health plan compliance management experience required
• Knowledge: Strong knowledge of federal, state, and local healthcare regulations, such as Health Insurance Portability and Accountability Act, Medicare/Medicaid rules, and Joint Commission standards.
• Skills: Excellent leadership, communication, and interpersonal skills to effectively collaborate with multiple stakeholders and teams. Analytical and problem-solving abilities to identify compliance risks and develop effective solutions. Ability to maintain confidentiality, exercise good judgment, and demonstrate ethical conduct.