Sr Manager Corporate Compliance-Special Needs Plans (Clinical)

Position Summary

The Sr. Manager is an experienced/career level compliance position that applies compliance, regulatory, business, analytical and communication skills to support, manage and develop and execute Medicare and Medicaid compliance programs and processes that promote compliant and ethical behavior, meet regulatory obligations, and prevent, detect and mitigate compliance risks.

Responsibilities

• Track, analyze, research, interpret, communicate and monitor applicable CMS and state regulations and government contract requirements to develop recommendations, direction, and escalation ensuring Aetna’s that implementation and integration of program requirements complies with federal and state specific program requirements and the CVS Code of Conduct
• Lead and implement an effective Compliance Program as described in CMS Medicare Managed Care Manuals/regulations, applicable Medicaid rules and government contracts, including risk assessment, auditing and monitoring and corrective action oversight
• Develop and manage compliance strategies, programs, and processes that promote compliant and ethical behavior, meet regulatory obligations, and prevent, detect, and mitigate compliance risks
• Maintain in-depth working knowledge and expertise in Medicare, Medicaid and State requirements, regulations and contracts with a focus on supporting special needs plans
• Support and/or facilitate multiple compliance and contract related communications, activities and interactions with regulators, including meeting with regulators on compliance with laws and regulations, developing or assisting in the development of appropriate and strategic written responses to compliance-related regulatory inquiries requiring an understanding of business processes and regulatory requirements and positive relationships with regulators
• Lead and/or support numerous external regulatory review and audit activities, including the preparation for and management of external audits conducted by CMS and state Medicaid and related agencies or partners in conjunction with health plan leadership through final report and corrective action plan closure
• Monitor and audit as outlined in Medicare Compliance Work Plan and direct other projects as assigned to evaluate compliance, propose remediation where necessary and monitor implementation of corrective action
• Utilize and maintain current information in systems unique to job functions, such as Microsoft products and compliance specific tools such as Archer
• Lead and support broader compliance initiatives and needs as assigned to ensure that effective compliance programs are achieved and maintained

Required Qualifications

• 7+ years experience in Medicare or Medicare Advantage government healthcare program compliance or regulatory work
• 2+ years of Project Management experience
• Ability to travel up to 10%
• Prior clinical or operational experience enabling interpretation of assessments, claims, and clinical documentation (RN, LPN, SW or similar role/ background preferred)
• Experience administering or overseeing SNP MOC and external quality requirements and reviews
• Bachelor's Degree OR equivalent experience required