Director of Medicare & Regulatory Compliance

Pay Range:

Please email [email protected] if you are a candidate seeking a reasonable accommodation for the application and/or interview process.

At BCBSRI, our greatest resource is our people. 

We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well.

We recognize that to do your best work, you have to be your best self. 
It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees.

Our culture is one of belonging.
We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued.

Join others who value a workplace for all.
We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. 

We’re dedicated to serving Rhode Islanders.
Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

Why this job matters:

Develop, implement, and monitor the Medicare and Medicaid compliance programs to ensure compliance with all applicable rules and regulations relating to Medicare and Medicaid operations. Assist the Corporate Compliance Officer in achieving goals and objectives; identify and resolve a variety of regulatory issues. Responsible for the development, implementation, and oversight of the auditing and monitoring processes. Ensure internal departments understand and implement Center for Medicare & Medicaid Services (CMS) and Rhode Island Medicaid rules, policies, and regulations. Serve as the company’s primary contact for CMS and the EOHHS. Ensure programs, plans, and policies align with the company’s philosophy and objectives.

What you will do:

• Provide direction and technical guidance to staff. Set goals, review, and evaluate work, and prepare performance reviews.

• Oversee the corporate Medicare Part C and D compliance programs. Serve as the Medicare Compliance Officer and subject matter expert on CMS rules, policies, and regulation.

• Oversee the corporate Medicaid compliance program. Serve as the Medicaid Compliance Officer and subject matter expert on RI rules, policies, and regulation.

• Partner with internal business areas to ensure compliance CMS and Medicaid requirements.

• Serve as primary relationship manager with CMS and RI Medicaid; respond to inquiries, complaints, and audits. Maintain a regular cadence of meetings with regulators to promote transparency and trust.

• With the Corporate Compliance Officer, conduct an annual risk assessment and develop an annual compliance audit plan for the company and its delegated vendors against federal, state and accreditation requirements and standards for all lines of business. Develop and oversee corrective action plans to remediate audit findings and monitor the implementation of corrective action plans.

• Ensure the timely and accurate submission of all regulatory filings and reports related to CMS and RI Medicaid.

• Develop and maintain internal processes to promptly review new regulations, interpret the regulation as it relates to company operational units; communicate regulations to the impacted business areas and ensure implementation of requirements.

• Coordinate annual and ad-hoc training to company associates related to Medicare requirements.

• Provide reporting and updates to the corporate compliance officer regarding company and New England Joint Enterprise (NEJE) Medicare and Medicaid compliance activities.

• Manage all CMS and RI Medicaid audits and site visits. Develop corrective action plans to remediate audit findings and monitor operational department’s implementation of such plans.

• Represent the company on the NEJE regional compliance workgroup and execute all compliance monitoring deliverables assigned to company. Collaborate with NEJE team members to address areas of non-compliance and work with vendor to remediate findings. Escalate areas of continued non-compliance within NEJE compliance structure.

• Develop and ensure adherence to goals and deadlines.

• Perform other duties as assigned.

What you need to succeed:

• A combination of education and related experience

• Seven to ten years of experience in Medicare or corporate compliance within the health insurance industry

• Five or more years of management experience or experience leading a team

• Experience designing, conducting, and monitoring compliance audits

• Strong knowledge of compliance principles, practices and procedures

• Knowledge of health insurance operations and healthcare issues, including managed care

• Knowledge of government healthcare programs (Medicare, Medicaid)

• Working knowledge of Medicare Part C and Part D requirements

• Knowledge of Pharmacy Benefit Manager (PBM) operations

• Ability to collaborate while dealing with complex situations

• Ability to think creatively and to drive innovation

• Ability to influence up and across the organization

• Ability to motivate, lead and inspire a diverse group to a common goal/solution with multiple stakeholders

• Ability to convert business strategy into action-oriented objectives and measurable results

• Ability to develop and manage a budget

• Strong negotiating, influencing, and consensus-building skills

• Ability to mentor, coach and provide guidance to others

The extras:

• Certified in Healthcare Compliance (CHC) or Certified Compliance and Ethics Professional (CCEP), Compliance & Ethics Professional Certification (CCEP)

• Experience interpreting and applying state and federal laws and regulations

• Knowledge of BCBSRI lines of business

Location:
BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia
   

Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today’s healthcare industry. BCBSRI is an equal opportunity employer.

The law requires an employer to post notices describing the Federal laws. Please visit  www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster.