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Director of Compliance

Irving, TX · Healthcare
Director of Compliance - Managed Care 
Irving, TX (Dallas-Ft Worth area)
Job Summary:
Coordinate, negotiate and direct the activities of the Medicare/Medicaid Compliance program and department staff to facilitate performance of all health plan responsibilities related to Medicare.  Including developing and implementing budgets and market planning; ensuing compliance of health plan/provider contracts; managing departmental workflow; and ensuring staff and program is in line with all related regulations. The Director of Medicare/Medicaid Compliance Operations is responsible to aid the chief administrative officer in formulating and administering organization policies and procedures related to meeting federal, state, and company Medicare regulations.
Position Description:
  • Oversee, administer, and implement various aspects of the Medicare/Medicaid Compliance program, including Health Plan Management System (HPMS) communication and regulation.
  • Ability to research and apply CMS, DOI, OIG, and HIPPA regulations to create processes and strategies while ensuring corporate compliance.
  • Coordinate and document company responses to Centers for Medicare & Medicaid (CMS) Requests for Information and related responses.
  • Provide guidance to various departments regarding compliance issues and ensure implementation of new compliance requirements with respect to regulatory and contract language.
  • Identify, evaluate and analyze the impact of CMS and Medicare regulatory issues and advise management concerning impact.
  • Partner with various departments to ensure that state and federal regulatory requirements are communicated and met.
  • Maintain and track laws and regulations, contract documentations, amendments, and various compliance measures
  • Ensure all Medicare/Medicaidproducts and services are being tested for compliance with program regulations, insurance regulations, and regulatory requirements for business entities.
  • Develop policies, procedures, and process to comply with federal program regulations, and any applicable state regulations; ensure policies and procedures are updated according to CMS and contract requirements.
Background Profile:
Clinical or Non-Clinical Professional with a Bachelor's Degree in Business, Leadership, or Health Care field; Master's preferred.
At least 4-6 years previous compliance program and contract experience with Medicaid/Medicare programs including conduct of internal and state audits.
Around 3-4 years’ experience working for a Managed Care Organization (Health Plan, IPA, TPA, MSO, etc).
At least 3-5 years experience with health care regulatory agencies in development or implementing of compliance and fraud programs.

Roughly 3-4 years previous management experience, in roles of increasing responsibility, including overseeing implementation of contract requirements; preferably as a Director or large scale Program Manager for a Managed Care Organization.
Broad-based background in health care and medical management is essential.
1-2 years demonstrated experience with contract negotiations and/or provider networking.
Requires knowledge of managed healthcare as applied to government sponsored programs.
Basic computer proficiency (MS Office and Healthcare IT Systems) and typing skills are necessary.
Understanding of operational reports, finical budgeting processes, and health care payment models.
Excellent verbal and written communication skills, as well as exceptional critical thinking skills.
Strong oral and written communication skills; ability to interact with internal and external contacts; able to provide representation to senior leaders on health plan issues relating to compliance and fraud program management.
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
The Reward:
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health. 


480.269.9491 (CALL – TEXT – FAX)
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