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The Vice President of Regulatory Compliance will oversee the strategy, design, development, implementation, and evaluation of the EmblemHealth Regulatory Compliance Program that identifies and monitors compliance with Federal and State laws including, but not limited to Medicare Advantage, Medicare Part D, Medicare Special Needs Plans, Medicaid, Medicaid Advantage, and Commercial lines of business (i.e., Essential Plan, Child Health Plus, Medicare Supplement, Health Insurance Exchange products). The role will present to the Board of Directors and the Combined Corporate Compliance Committee of the Board of Directors as needed and upon request. In addition, they will expand the Regulatory Compliance program to include all government programs such as Medicare Advantage, Medicare Part D, Medicare Advantage Special Needs Plans, Medicaid, Medicaid Advantage, CHIP, MLTC, FIDA, and Commercial lines of business, such as the Essential Plan, Medicare Supplement and health insurance exchange products.
Additional responsibilities include the following-
Maintain a working knowledge of relevant issues, laws and regulations affecting the organization and industry. Works with various outside external entities including, DFS, DOI, DOH, AHIP, and Attorney General on behalf of the enterprise.
Plan and perform a comprehensive mock audit program, including an annual Medicare Compliance Program Assessment or other special projects that assist the organization with accomplishing its objectives by evaluating and improving the effectiveness of internal control process(es).
Oversee and coordinate of all external audits with the Centers for Medicare and Medicaid Services, Human and Health Services, Office of the Inspector General, and the Department of Health. Collaborates with state Medicaid programs, Medicaid Fraud Control Units, commercial payers, and other organizations when a fraud, waste or abuse issue is discovered to involve multiple parties.
Oversee the organization’s Delegate Oversight and Vendor Management programs, including administration of the Delegate Oversight Committee, management of annual delegate audits, facilitation and confirmation of delegate corrective action preparation and implementation, monitoring vendor data reporting, and facilitating vendor corrective action plan preparation and implementation.
Direct the identification and evaluation of Enterprise-wide regulatory risk areas through an annual risk assessment process and the development of the annual Compliance Auditing and Monitoring Plan. Responsible for the risk management issues that directly impact the strategic direction of the organization. Charged with delivering the strategy to the company by identifying, evaluating, mitigating and monitoring various risk factors.
Report to Senior Management to advise on all potential risk and exposure to the Plan.
Master’s Degree in Healthcare administration, Business, or Related Field) or other Advanced Degrees (Juris Doctor, Medical Doctor).
15+ years of relevant experience
Experience working in or with CMS and other government regulatory agencies.
Certification in Healthcare Compliance preferred.
EmblemHealth is a local, neighborhood health plan that has served the New York City area and surrounding communities for more than 75 years. That’s the kind of experience that makes us unique. We’re proud to be one of the nation’s largest not-for-profit health plans, serving 3.1 million people who live and work across the New York tristate area.