Lead Compliance Program Manager

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Job Summary

The Lead Compliance Program Manager will be responsible for development, implementation and management of significant and complex compliance programs, initiatives and projects associated with federal and state regulations for applicable lines of business (Corporate, Commercial, Medicare, Duals and/or Medicaid). This work requires partnering with internal departments as well as external stakeholders including government regulators and auditors. The Lead Compliance Program Manager will be responsible for collaborating with leadership, teams and partnering departments to define and execute strategic compliance initiatives in order to accomplish successful compliance oversight and maintain an effective compliance program. The Lead Compliance Program Manager should make recommendations for change by performing risk analysis and by using basic analytical and problem-solving capabilities to support the recommendation. Responsibilities at this level usually require facilitating cross-departmental meetings and negotiations with outside parties and regulators to explain and assess the impact. The Lead Compliance Program Manager will also interact directly and regularly with leadership within the department and within Point32Health to accomplish successful compliance oversight and maintain an effective compliance program.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Provide support in overall management of the compliance program key functions, including developing compliance workplans across all elements of an effective compliance program, including (but not limited to): Risk Assessment; Monitoring and Auditing; Effective Communication; Training and Education; Policies and Procedures; Vendor Oversight; Issue correction and remediation.
• Ensure ongoing compliance with established, revised, or new regulatory requirements that impact the organization, including delivery of benefits for members.
• Oversee the compliance program through employee and leadership communications, coordination of policy development and ensure accurate and timely communication to all departments.
• As applicable, conduct risk assessments, focused reviews, and/or audits to identify potential compliance issues and vulnerabilities. Effectively identify regulatory and compliance risks and provide plan of remediation.
• Management of significant or complex regulatory audits to ensure timely completion of data and documentation collection, review, and submission. Perform review of regulatory audits results. Support development of responses. Track monitoring of responses and remediation actions.
• Lead and/or manage projects and/or initiatives by representing regulatory and compliance expectations and requirements during planning and implementation phases. This may include coordinating issue resolution with relevant functional business areas, and leading and/or facilitating planning and review sessions.
• Evaluate and analyze regulations and sub-regulatory guidance, interpret their significance and recommend and review policies to ensure compliance.
• Manage tracking, investigation, and resolution of compliance oversight activities such as issue management, monitoring and auditing. Lead and coordinate responses to compliance violations and incidents.
• Investigate instances of suspected noncompliance within the health plan and report to appropriate management and regulators, if required.
• Prepare monthly and/or quarterly compliance reporting for the organization’s leadership and organizational Committees.
• Understand regulatory requirement and industry to help drive a successful compliance program through prevention, detection, and correction of potential issues of noncompliance and/or fraud.

Qualifications – what you need to perform the job

Education, Certification and Licensure

• Bachelor's degree: in business, law, compliance, or a related field preferred.
• Advanced degrees and relevant certifications are a plus.

Experience (minimum years required):

• 8 or more years of regulatory, compliance and legislative activities, health insurance operations or legal research or equivalent combination of education and experience. 3 – 5 years of Medicare, Medicaid and/or Commercial compliance experience. Demonstrated knowledge of government regulations as they relate to the administration of Medicare and/or Medicaid healthcare programs, principles, and practices of managed care.

Skill Requirements

• Excellent verbal and written communication skills generally acquired through college or other advanced education is required, ability to facilitate planning and review sessions.
• High level presentation skills including ability to interface effectively with internal and external contacts and present technical information in a way that establishes rapport and gains understanding.
• Ability to exercise sound judgment and raise issues and potential solutions to appropriate team members or management for resolution;
• Ability to conceptualize the impact of change and propose new methods of conducting business
• Strong analytical skills to develop new or implement change to existing program functions
• Ability to interpret and explain the implications of planned changes to current state business units
• Ability to problem solve and overcome obstacles to ensure successful program operations

Technical skills:

• Proficiency with MicroSoft Office applications (Word, Excel, PowerPoint)
• Ability to utilize multiple applications simultaneously

Interpersonal skills

• Requires the ability to work cooperatively as part of a team.
• Must be able to effectively communicate with all internal departments in verbal and written formats.
• Must be able to work in a matrix environment with minimal supervision
• Using knowledge of the company, able to resolve most roadblocks to program progress. Ability to operate and thrive in a matrixed-management, hands-on environment that demands a consultative approach and solutions environment with minimal supervision. May need to coordinate the participation of other internal contacts to develop and or maintain programs.
• Able to navigate issues using advanced organizational knowledge. Is an effective, strong advocate for the program and negotiates/leads others both internally and externally to participate to ensure success in the program. May be required to coach/mentor less experienced staff and effectively lead in a matrixed environment.
• Proactively identifies conflict/integration issues and leads team members to parse/synthesize issues of the highest complexity. Ability to identify risk out of the larger picture and develop risk analysis for consideration.
• Detailed content knowledge of the specific program. Must be able to converse and lead dialogue on the subject with minimal direction; advanced training in the field related to the program is preferred.
• Must be flexible and a proponent/champion of change, able to conceptualize and envision the impact of change, and propose new ways to do business.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Fast-paced office environment handling multiple demands
• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent.  We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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