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Director Medicare Compliance

Portland, OR, USA | Providence Health & Services

  • Industry:
    Healthcare - Hospitals
  • Position Type:
  • Functions:
    General Management
    Legal / Compliance
  • Experience:
    5-7 years
Job Description:
72 people have viewed this job

Providence St. Joseph Health is calling a Director Medicare Compliance to our health plan’s locations in Beaverton and Portland, OR.

Position can be performed remotely with occasional travel for internal meetings

We are seeking a Director Medicare Compliance who will serve as the health plan's Medicare compliance officer. This position is responsible for administering and managing Providence Health Assurances (PHA) enterprise-wide Medicare Advantage compliance program as well as compliance programs for other partners and affiliates. This position defines the Medicare Advantage compliance program structure, educational requirements, reporting, and complaint mechanisms, response and correction procedures and compliance expectations for all personnel and contractors. It is responsible for monitoring and reporting the status of compliance program effectiveness to the Chief Compliance Officer, senior executives and provides reports for the Board.

This position provides daily oversight and management of Medicare Advantage compliance programs including assessment and mitigation of compliance risks as it relates to operations. Responsibilities include managing the development, implementation and evaluation of enterprise-wide regulatory compliance activities for PHA's Medicare programs, and programs of its partners and affiliates. The Director manages the working relationships with CMS and is responsible for developing, managing and communicating internal subject matter expertise regarding regulatory and contractual requirements as well as provides consultation to internal staff and leadership at PHA, PSJH and other partner organizations. Advises appropriate leadership regarding legislative and public policy issues affecting Medicare.

In this position you will have the following responsibilities:

  • Leading PHA's and other partners and affiliates' efforts to assure compliance with Medicare Advantage programs rules and regulations.

  • Responsibility for fostering and maintaining the relationship between PHA and CMS (Medicare), ensuring a positive working relationship with PHA's regulator.

  • Developing and/or overseeing the comprehensive Medicare compliance program for PHA, including responding to all compliance questions or concerns; managing/developing, revising and presenting Medicare-specific training programs for PHA's caregivers, sales staff and first tier, downstream and related vendors.

  • Manageing the interpretation and dissemination of all Medicare guidance to leadership and staff, while considering continuously changing landscape from CMS.

  • Maintaining and developing subject matter expertise (including staff development) regarding regulatory compliance and public policy issues affecting Medicare Advantage.

  • Responsibility for developing and managing process for new product and service area expansions application filings to CMS. Responsible for compliance aspects for implementation of new products and service area expansions.

  • Overseeing all Medicare Advantage reporting ensuring deadlines are met and fines/sanctions are not imposed.

  • Overseeing the preparation and submission of proposed Medicare marketing materials to CMS, tracking approval status and communicates same to all involved PHA staff.

  • Responsibility for managing staff, including hiring, coaching, development and discipline.

  • Managing and/or overseeing Medicare/CMS external audits, risk adjustment validation audits, data validation audits and other CMS ad hoc or targeted audits. Responsible for developing responses and corrective action plans as required.

  • Maintaining up-to-date knowledge of current and emerging policy issues regarding Medicare Advantage legislation, regulations, market activity and industry trends and providing timely internal communication. Ensuring PHA's compliance with federal laws, rules, regulations manual and transmittals pertaining to the Medicare Advantage program.

  • Responsiblity for the success of PHA Medicare Advantage auditing and monitoring as well as PHA's delegation oversight programs.


Required qualifications for this position include:

  • Bachelor's Degree in Business Administration, Economics, Healthcare Administration or other related field or equivalent education/experience.

  • 5 years demonstrated successful and progressive staff and/or management experience.

  • 5 years demonstrated successful experience working with administrative, policy, legal, audit, regulatory compliance and/or operational aspects of managed care plans.

Preferred qualifications for this position include:

  • Master's Degree or J.D in Healthcare Administration, Business Administration or related field.

  • 7 years of experience in Medicare Advantage.

About Providence in Oregon.

As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.

The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple, "Providence will provide the best care and service to every person, every time."

Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

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