Sr. Director, Third Party Compliance Oversight

Why This Role is Important to Us: The Senior Director, Third Party Compliance Oversight reports directly to the SVP, Corporate Compliance & Ethics and Risk Operations, and leads the Third-Party Compliance Oversight department for Commonwealth Care Alliance (CCA). This position effectively leads our Third-Party Compliance Oversight programs which includes monitoring and evaluating the performance of delegated third parties according to CMS, federal, and state requirements in a manner that continually supports the business and operational areas. What You'll Be Doing: Strategically leads the Third-Party Compliance Oversight Department staff that perform compliance oversight and monitoring of delegated third parties including Medicare FDR; Duals/SNP; and Medicaid/LTSS programs. Coordinates and reviews work completed by Third-Party Compliance staff including risk assessments, compliance program reviews, pre-delegation screenings and various items for accuracy and completeness. Manages and monitors third parties against CMS, contractual, federal, and state requirements. Ensures strategic and operational partnership and collaboration with the business and operational areas, as well as with GRC teams to leverage cross-departmental synergies and efficiencies. Maintains strong communication and working relationships with internal and external business partners. Develops clear, effective, and timely reports and updates for senior management and/or the Board regarding Third-party Oversight Compliance Program effectiveness, initiatives, and issues, including all relevant metrics, dashboards and information. Reviews, researches, interprets and summarizes federal and state regulations and ensures timely training of key personnel impacted by new or changed regulations. Facilitates and participates in team and committee meetings, providing ideas and suggestions to ensure compliance standards are met. Assesses, investigate, and resolve issues to ensure customer satisfaction. Maintains a positive work environment and supports the experience, skill, knowledge, and growth opportunities of all employees. Coordinates and performs on-going monitoring of third-party activities to ensure compliance. Works closely with the Governance, Risk & Compliance (GRC) teams (Medicare, Medicaid, Privacy, Fraud, Waste & Abuse) for dissemination of new or revised requirements applicable to the delegated third-party. Oversees, develops, and maintains reporting and metrics for delegated third-party activities. Ensures timely receipt of accurate and complete reporting for all regulatory and contractually required reports for delegated third parties. Oversees the process for completing Third-Party Pre-Qualification/Delegation Assessments. Oversees the process for Third-Party Annual Attestations. Oversees and conducts risk assessments for each third-party. Develops and maintains oversight document evidence related to compliance oversight in preparation for state, federal and regulatory audits. Monitors and audits delegated third parties to ensure compliance with state and federal requirements. Executes compliance monitoring plans to monitor delegated third parties to meet regulatory oversight and compliance requirements. Oversees, develops, assesses, and adapts clear and effective remediation and corrective action initiatives, protocols, and controls to ensure proper and timely compliance. Stays abreast of changing industry requirements and regulations, including all relevant laws, rules, contractual agreements, industry standards, company practices and initiatives. Provides clear and effective reports to the relevant business, functional and operational areas, as well as other internal/external stakeholders, regarding new laws, regulations, contractual requirements, industry standards and best practices. Performs other duties as assigned. What We're Looking For: Demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of colleagues and members. Approach work in a collaborating and caring manner interacting with insight, sincerity, and compassion. Demonstrate accountability by delivering on commitments, owning mistakes as well as successes, and contributing to an empowering environment where the focus is on solving problems and learning from errors. Recognize and respect diversity in all forms. Strive for excellence in the fulfillment of CCA's mission through quality, innovation, and continuous learning. Demonstrate initiative, flexibility, and openness to change. Represent CCA and its clinical affiliates with professionalism. Keep current and proficient with necessary skills and knowledge. Self-identify training and development needs relevant to work area and responsibilities. Adhere to all applicable compliance requirements including but not limited to: Complete required compliance training in a timely manner Review Code of Conduct at least annually and promote and enforce CCA's Code of Conduct Promote and enforce CCA's compliance program Adhere to CCA's Policy & Procedures Promptly, in good faith, report any instances of suspected fraud, waste and abuse; suspected privacy and/or security incidents; or any compliance concerns identified Ensure confidentiality of member and company proprietary information is maintained Required: Bachelor's Degree Minimum of 8-10 years delegation oversight, vendor management, health insurance government products and programs (Medicare, Duals/SNP, Medicaid, LTSS), and/or compliance experience required, on the insurance (payor) side. Minimum of 5 years of work experience in a managerial/leadership role managing a team directly. Strong subject matter expertise and knowledge of all relevant laws, regulations, contractual requirements, industry standards and best practices required. Strong acumen and understanding of healthcare, health insurance and managed health care industries and organizations required. Strong partnership-, relationship-, consensus- and coalition-building skills required. Strong emotional intelligence and self-awareness required. Strong executive polish and presence required. Strong strategic, business, operational, and leadership mindset and skills required. Highly consultative and partnership-oriented in approach. Strong ethical compass and integrity capital required. Excellent organizational, analytical and problem-solving skills, as well as oral, listening and written communication skills, required. Strong ability to synthesize complex requirements and clearly and concisely articulate the relevant points. Strong program and project management skills and experience required. Ability to influence at all levels of the organization, including executive management; the Board; regulators; employees; customers; partners and vendors. Strong strategic, business, operational and leadership mindset and skills required. Highly consultative and partnership-oriented in approach. Must have strong analytical and organizational skills as well as problem-solving capabilities to ensure that business plans and strategies do not subject the organization to legal, regulatory or contractual violations and/or undue risk or exposure. Strong and reliable judgment and discretion required. Strong ability to independently and self-sufficiently identify and navigate various operational issues. Desired: Relevant graduate degree (e.g., Juris Doctor or master's degree in a related field) EEO is The Law Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

Created: 2024-10-19