Compliance Specialist | Health Plan
Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.
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Facility: Cherapa Place Building
Location: Sioux Falls, SD
Job Schedule: Full time
Weekly Hours: 40.00
The government programs compliance specialist demonstrates expertise in Medicaid Expansion, Federal Exchange, Medicare Advantage and Part D health plan operational compliance and compliance program requirements. Acts as the strategic internal business partner serving as the lead subject matter resource for Government Health Plans regulations and requirements. Routinely meets with corporate line management to assess business operations against all Government Health Plan regulatory requirements and provide in-depth interaction, communication and oversight that touches Government health plans relative to meeting Centers for Medicare and Medicaid Services (CMS) requirements and applicable state requirements.
Develop, maintain, and update an annual compliance risk assessment, in addition to monitoring and auditing the work plan. Develop appropriate compliance reports; including dashboards, tracking logs and summary reports that communicate the status of the compliance program to leadership.
Develop and administer internal auditing and monitoring procedures that assess operational performance against CMS and applicable state standards. Distribute clear audit reports that describe audit risks and failures with appropriate business leaders to identify and track compliance assurance process (CAP).
Act as point of contact with CMS and state regulators. Ensure operational preparation for CMS, state program and compliance audits. Lead monitoring activities across multiple operational areas to identify areas of potential compliance risk and develop solutions for risk mitigation. Implement vendor oversight program, including focus on government health plan vendors.
Analyze and communicate new and changed policy and regulations to all business areas. Track implementation. Develop relevant annual compliance training for distribution to all appropriate staff. Provide written and oral advice and guidance regarding compliance requirements that impact the company's products and business.
Tailor Corporate Compliance materials to apply to Government health plans. Review new rules and regulations and consult with business partners to implement. Oversee and monitor regulatory submissions.
Responsible for project management within the compliance team. Manage projects in a matrixed environment. Completion of deliverables in accordance with established timelines and processes. Work with outside entities, including vendors, CMS, state regulators, external association representatives, consultants, and other health plan compliance professionals to achieve the company's goals and compliance with CMS and state requirements.
Demonstrate superior project management skills. Keen verbal and written communication skills. Critical thinking and analytical skills. Ability to apply government regulations and translate those to business requirements. Ability to manage timelines and multiple priorities and projects.
Bachelor’s degree required. Field of study in business, healthcare, public policy, accounting or other related area preferred. Master’s degree preferred.
Four to six years of Health Plan, Medicaid Expansion, Medicare Advantage and Part D or Federal Exchange experience strongly preferred. Preferred experience working in healthcare compliance, audit or operations. Experience with overseeing implementation of contract requirements. Previous experience demonstrating effective communication with federal and state regulatory agencies preferred. Knowledge of Medicare, Medicaid, and CMS regulations and software applications tools preferred.
Sanford is an EEO/AA Employer M/F/Disability/Vet.
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Job Function: Legal and Compliance
Req Number: R-25399