Director, Health Plan Operational Compliance

Responsibilities

• Lead the development of the strategy, planning and execution necessary to effectively implement legislation and facilitate implementation of strategies and processes that ensure compliance and achieve operational effectiveness and efficiencies.
• Develop and deploy communication and training initiatives that support operational compliance goals and obligations.
• Establish standards and procedures for reporting and documentation, monitoring results against specifications, investigation and mitigation of compliance issues.
• I n partnership with the Enterprise Compliance Office , c ollaborate with other BCBSNC staff throughout the Health Plan to direct compliance issues to appropriate channels for investigation and resolution.
• Lead, manage and set goals for teams responsible for identifying , coordinating, and implementing initiatives/projects and activities that create efficiencies, optimize systems & processes, and promote compliant outcomes
• Provide leadership, vision, and direction for assigned teams:
• Accountable for all decisions within the group.
• Determine team priorities to reflect the organization's core values and deliverables.
• Develop , coach and motivate others to take actions that support and reflect the core values and desired future state.
• Develop and manage departmental budgets including forecasting and variance analyses.
• Lead initiatives to develop, modify , and improve the effectiveness of the department by looking at processes, root cause analysis, system enhancements, re-engineering, etc.
• Direct staff of subject matter experts and analysts on supporting business initiatives, production problem resolution, system enhancements, and configurations to ensure compliant outcomes
• Lead and oversee management and delivery of enterprise and departmental projects including business case development, ROI analysis, planning, business analysis, and project management.
• Lead and oversee optimization of existing systems, processes, and workflows to ensure compliant outcomes.
• Direct the overall integrity and functionality of departmental business applications and processes o System administration support to include providing guidance on configuration coding, and oversight of system configuration to ensure compliant outcomes .
• System administration support to include providing guidance on configuration coding, and oversight of system configuration to ensure compliant outcomes .
• Pr ovide expertise and guidance on pr oduct implementation and enhancement to ensure compliant outcomes .
• Research , analysis, and user assessment of technology and systems to ensure adequate application capabilities to produce compliant outcomes
• Lead and oversee Operational Compliance strategies, programs, training, and/or policy and procedure development and documentation including interfacing with external audit programs (e.g. DOI, CMS, other third party regulatory bodies).
• Serve as business owner for key corporate, divisional, and departmental initiatives.
• What You Have
• Bachelors degree or Advanced Degree
• 10 years experience in health insurance, health care operations or legal with at least 4 of those years in a compliance, regulatory and/or Medicare role.
• Detailed knowledge of state and federal insurance law, especially health insurance and managed care.
• 5 years of progressive leadership experience.
• Experience managing remediation of complex compliance issues and legislative implementations.
• In lieu of degree, 12+ years of experience in related field
• Bonus Points
• Strong preference for dual expertise in: Health Care Operational and Compliance leadership
• Can connect policy → process → compliance outcomes
• Experience influencing or designing workflows/processes
• What You 'll Get

Benefits

Additional Information

Job Description Provide leadership, vision, and direction for the defined units within their business area, to include Medicare, Commercial, and FEP Compliance. Lead and set goals for teams responsible for identifying, coordinating, and implementing strategies, frameworks, initiatives/projects and activities that create efficiencies, optimize systems & processes, and promote compliant outcomes. Lead multiple teams united to ensure the integrity within the Health Plan that reflects clear alignment to our enterprise compliance program, as well as regulatory and contractual requirements and policies. Our team creates impact through engagement with business areas to achieve compliant outcomes, including consultative services, project planning, and project leadership, mitigation plan development, compliance audit support and readiness activities, material assurance and agent behavior assurance.

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