This position is responsible for developing and maintaining a Regional Medicaid Compliance Program designed to partner closely with the KPMAS Medicaid Office and MAPMG to advise regional staff on contract and regulatory Medicaid requirements in Maryland, Virginia and the District of Columbia; develop functional procedures compliant with state Medicaid program requirements; monitor performance with Medicaid compliance requirements; and conduct education and training of appropriate personnel on state programs compliance issues, as needed. The Medicaid Compliance Program Manager will serve as the point person to facilitate external and internal Medicaid Regulatory Audits. This includes audit preparation, facilitating the collection of pre-audit materials, and working with the Medicaid Operations Team and other internal business partners to develop, report and monitor any associated action plans responding to audit recommendations or other issues of non-compliance. In addition, this position is responsible for maintaining an informational reporting relationship and information exchange with the National Compliance Office.
Monitor and evaluate regional compliance with state programs contract(s) and Medicaid regulatory requirements. Advise regional departments and staff on Medicaid requirements related to regulatory Medicaid requirements in Maryland, Virginia and (eventually) the District of Columbia. Develop agreement among regional leaders and managers of key departments to provide oversight of compliance activities across all work teams and processes that affect state programs members of KPMAS. Review and oversee submission and negotiation for approval of all marketing materials.
Work effectively with Health Plan and MAPMG leaders and our labor partners to effectively provide compliance oversight of Medicaid program. Create and establish effective means of interdepartmental communication and coordination of state programs compliance contract issues and activities both directly and through the appropriate committee structure. Present state programs compliance and regulatory issues at meetings with appropriate operations areas, and serve on appropriate compliance workgroups as directed by the VP, Regional Compliance Officer or Compliance Director. Participate on state contractors committees as appropriate. Participate on Medicaid workgroups or projects with the National Compliance Office.
Interpret state and local Medicaid requirements for affected departments and assist departments in developing operational policies and procedures, specialized training and other functions to comply with state programs contract requirements, regulations, operational policy letters and others guidance. Communicate to organizational departments new or changing legislation and contract requirements. Assist the organization in accessing impact of the changes and provide compliance oversight for the implementation of new or revised regulatory requirements related to the Medicaid contracts.
Work with operational teams to develop internal monitoring tools that evaluate compliance with Medicaid requirements. Review the results of internal monitoring and work with the operational areas to develop corrective actions when noncompliance is identified. Conduct risk assessments of operational processes and functions in order to prioritize where additional compliance review is warranted. Develop and conduct adhoc audits of processes to ensure compliance with contract requirements and internal policies and procedures.
Coordinate preparations for state and local contract monitoring visits and for internal audits. Coordinate the development of corrective action plans and appropriate activities following an audit. Assure timely submission of corrective action plans to the state agencies and respond timely to other items, pertaining to audits from the state agencies. Serve as primary contact with State agency personnel for issues related to compliance with the Medicaid contracts.
Other duties as assigned by the VP, Regional Compliance Officer or Director, Audit Readiness, Legislative and Product Compliance.
Minimum five (5) years experience in compliance in a health insurance product and/or health insurance regulatory setting required.
Minimum three (3) years experience working with Medicaid contract or similar negotiated documents.
License, Certification, Registration
Experience in interpreting statutes and regulations and working in a regulatory environment.
Experience performing audits and/or preparing for and responding to regulatory audits by federal and state regulators.
Demonstrated ability to interpret complex data.
Demonstrated ability to effectively collaborate with executive and medical staffs, administration, department heads and other personnel, as well as external contacts.
Demonstrates customer-focused services skills.
Demonstrated ability to work independently and motivate people to achieve shared goals is required.
Demonstrates clear organizational skills.
Excellent written and verbal communication skills.
Experience in education, training and oral presentation.
Experience with PC, relevant applications, analytical and statistical skills.
Project management skills.
Skills in negotiation and conflict resolution.
Demonstrates problem solving and decision making skills.
Ability to manage complex report structure required.
Project management skills (Demonstrated ability to manage multiple large complex priorities and projects and meet deadlines).
Experience with Virginia, Maryland and DC regulations, Medicaid, standards and MCO requirements.
Strong financial background.
Ability to interpret data and collaborate with teams.
Demonstrated effective ability to work with executive and medical staffs, administration, department heads and other KPMAS personnel, as well as external contacts.
Professional certification in healthcare Compliance (CHC).
J.D. or Master's Degree
Internal Number: 712958
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