Compliance Team Lead

Meridian Detroit , MI 48222

Posted 4 months ago

Overview

Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.

We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.

Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.

Responsibilities

Essential Functions:

  • Lead comprehensive compliance audits in high-risk areas pursuant to the annual workplan

  • Be a strategic thought partner to teammates and stakeholders and be able to anticipate internal and external threats

  • Conduct monitoring reviews in high-risk areas pursuant to the annual workplan

  • Supervise the training of new staff and answers questions from the staff as needed

  • Serve as a role model for Compliance staff for meeting department and corporate goals and deliverables

  • Acts as the first line of review for work products to ensure accuracy

  • Lead project planning and oversee project timelines and/or implementations for timely completion.

  • Assist in managing CMS and other external audits

  • Conduct (and assist the Medicare Compliance Officer in conducting) training operational departments on compliance topics

  • Lead FWA efforts, fraud investigations, data mining, recovery and predictive claim analytics

  • Work with business owners to implement process improvement initiatives

  • Maintain and actively lead all Corrective Action Plan (CAP) efforts towards resolution

  • Work with leadership and executives to resolve issues and build new processes

  • Report (and assist the Medicare Compliance Officer in reporting) compliance initiatives and projects to the Medicare Compliance Committee

  • Maintain industry-leading knowledge of Medicare regulations and serve as SME in interpreting such regulations. Communicate such regulations to the affected departments and facilitate the implementation of necessary action

  • Develop new, and review existing, Medicare & Medicaid policies & procedures

  • Handle reported issues of noncompliance, investigate and track them to completion

  • Lead (and assist the Medicare Compliance Officer in leading) operational projects, such as annual application, bid, and service area expansion

  • Work with Quality Management on improving HEDIS, CAHPS, and HOS scores (as well as other areas measured by CMS) in order to achieve a 5-Star Quality Rating

  • Initiate, facilitate, and promote activities to foster compliance awareness and to encourage reporting of compliance issues within the organization and related entities

  • Remain updated on all member and provider policy changes made by the health plan, CMS and/or the State

  • Assist the Medicare Compliance Officer with assigned tasks as requested

  • Perform other duties as assigned

Qualifications

Job Requirements:

Education:

  • Bachelor's degree or Fellow Designation from the Academy of Healthcare Management (AHM) is required

Experience:

  • Experience with Medicare required

  • Experience with Part D preferred

  • Experience working for a PBM preferred

  • Customer service experience or related health care industry experience is preferred

  • Experience with MHP's managed care system (MCS) is preferred

  • Demonstrated adaptability and flexibility to changes and response to new ideas and approaches is required

Knowledge:

  • Knowledge of managed care and the Medicare program is required

  • Knowledge of the health plan programs, benefits, and services for all lines of business for our members

  • Knowledge of auditing principles is preferred

Skills:

  • Superior verbal and written communication skills

  • Superior analytical and problem solving skills

  • Superior attention to detail

  • Excellent computer skills

  • Willingness to work in a team environment with a great sense of customer focus

Abilities:

  • Ability to be patient, courteous and polite to all members, providers and internal customers in all situations

  • Ability to multitask and juggle multiple projects with competing deadlines and priorities

  • Ability to take on an above-average workload

  • Ability to learn new skills and acquire knowledge

  • Ability to think independently and solve problems

  • Ability to take proactive actions with minimal supervision

  • Ability to work with leadership and senior management

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