Government Programs Compliance Lead

Responsibilities

• Support the Medicare Compliance Officer in the execution and continuous improvement of the compliance program, ensuring alignment with CMS requirements and the 7 elements of an effective compliance program, with a focus on proactive risk identification and mitigation.
• Operationalize compliance program elements, including:
• Policies and procedures development and implementation
• Training and awareness initiatives
• Monitoring, auditing, and data-driven oversight
• Issue identification, investigation, and corrective action planning

Requirements

• Deep knowledge of CMS Medicare regulations and guidance (including 42 CFR Parts 422/423, CMS manuals, HPMS guidance, and audit protocols)
• Understanding of the 7 Elements of an Effective Compliance Program and ability to operationalize them across Medicare Advantage and Part D programs
• Knowledge of Medicare Part D and/or MA-PD program requirements including enrollment, claims, formulary, pharmacy operations, and member protections
• Knowledge of Fraud, Waste, and Abuse (FWA) requirements and detection methodologies including exclusion screening, investigations, and reporting obligations
• Ability to conduct regulatory gap analyses and translate requirements into actionable controls across operational functions (e.g., claims, UM/CM, network, enrollment)
• Strong auditing and monitoring capabilities including development of work plans, identification of compliance risks, and use of data-driven oversight
• Knowledge of CMS audit processes and audit-readiness expectations including document production, universes, and issue remediation lifecycle
• Ability to interpret and apply regulatory requirements to complex business scenarios and provide practical, risk-based compliance guidance to operational stakeholders
• Knowledge of privacy, data governance, and handling of sensitive information particularly as it relates to Medicare data and compliance investigations
• Strong analytical and problem-solving skills with the ability to identify root causes of compliance issues and recommend sustainable solutions
• High level of professional integrity and judgment including the ability to identify, escalate, and address potential compliance risks or noncompliance

Qualifications

• BS
• 7+ Years Experience

Skills and Abilities

• Deep knowledge of CMS Medicare regulations and guidance (including 42 CFR Parts 422/423, CMS manuals, HPMS guidance, and audit protocols)
• Understanding of the 7 Elements of an Effective Compliance Program and ability to operationalize them across Medicare Advantage and Part D programs
• Knowledge of Medicare Part D and/or MA-PD program requirements including enrollment, claims, formulary, pharmacy operations, and member protections
• Knowledge of Fraud, Waste, and Abuse (FWA) requirements and detection methodologies including exclusion screening, investigations, and reporting obligations
• Ability to conduct regulatory gap analyses and translate requirements into actionable controls across operational functions (e.g., claims, UM/CM, network, enrollment)
• Strong auditing and monitoring capabilities including development of work plans, identification of compliance risks, and use of data-driven oversight
• Knowledge of CMS audit processes and audit-readiness expectations including document production, universes, and issue remediation lifecycle
• Ability to interpret and apply regulatory requirements to complex business scenarios and provide practical, risk-based compliance guidance to operational stakeholders
• Knowledge of privacy, data governance, and handling of sensitive information particularly as it relates to Medicare data and compliance investigations
• Strong analytical and problem-solving skills with the ability to identify root causes of compliance issues and recommend sustainable solutions
• High level of professional integrity and judgment including the ability to identify, escalate, and address potential compliance risks or noncompliance

Benefits

• Comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account and many other benefits

Pay

The Posting Range For This Position Is 113,572.92 - 153,590.12

Schedule

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.