Description:
Verda Healthcare, Inc. is a Medicare Advantage Prescriptions Drug Plan (MAPD) organization committed to the idea that healthcare should be easily and equitably accessed by all, currently available in Texas and Arizona. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a Sr. Manager or Associate Director of Compliance to join our growing company with many internal opportunities.
Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare is looking for people like you who value excellence, integrity, care and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.
Align your career goals with Verda Healthcare, Inc. and we will support you all the way.
Position Overview
The Senior Manager or Associate Director of Compliance will support the Medicare Compliance Program and ensure compliance with CMS and state regulatory requirements. This position reports to the Chief Compliance Officer and will assist in overseeing compliance operations, policies, training, risk management, internal and delegated auditing and monitoring, and will work closely with internal departments to promote a culture of compliance.
This position reports to Chief Compliance and Risk Officer.
Responsibilities:
- Act as a key compliance advisor, providing regulatory guidance and ensuring adherence to Medicare compliance requirements.
- Assist in developing, maintaining, and revising compliance policies and procedures to support the organization’s regulatory responsibilities.
- Oversee and coordinate compliance training programs to ensure that employees and delegated entities understand their regulatory obligations.
- Lead internal and delegated entity auditing and monitoring efforts to ensure compliance with CMS regulations, contractual obligations, and internal policies.
- Implement and oversee risk management processes, identifying, assessing, and mitigating compliance risks.
- Conduct routine monitoring and internal audits, evaluating compliance effectiveness and identifying areas for improvement.
- Support the development and implementation of corrective action plans in response to compliance concerns, audit findings, and identified risks.
- Collaborate with internal stakeholders and delegated entities to ensure compliance-related issues are effectively addressed.
- Collaborate with Claims, Finance, Utilization Management, Quality, Stars, SNP, and other operational departments to support compliance with applicable CMS and state regulatory requirements.
- Support compliance oversight of claims operations, including monitoring related to claims timeliness, payment accuracy, denial requirements, claims reporting, and corrective action activities.
- Assist with finance-related compliance oversight, including review and tracking of regulatory filings, solvency-related documentation, financial reporting obligations, and compliance support for finance operations.
- Support compliance oversight of utilization management activities, including organization determinations, prior authorization, medical necessity review, timeliness standards, and applicable CMS UM requirements.
- Assist with SNP compliance oversight, including Model of Care requirements, care coordination activities, HRAs, ICPs, ICTs, and SNP-specific CMS expectations.
- Support Quality and Star Ratings compliance activities, including monitoring quality improvement initiatives, member experience activities, measure performance, data tracking, and cross-functional action plans.
- Assist in regulatory reporting and responses to external agencies, including CMS and state regulators.
- Promote compliance awareness through effective communication strategies, including the use of a compliance hotline and adherence to the Code of Conduct.
- Support compliance investigations, including root cause analysis and impact assessments, while working with Human Resources on necessary disciplinary actions.
- Stay informed on regulatory updates and changes in Medicare and Medicaid requirements, translating them into actionable guidance for the organization.
- This position requires daily in-office attendance to ensure effective collaboration and oversight of compliance activities.
- Other duties as assigned.
Requirements:
Minimum Qualifications
- Bachelor’s degree in healthcare, business, or a related field required. Master’s degree or JD preferred.
- At least 5 years of Medicare Advantage and Prescription Drug Plan compliance experience.
- At least 5 years of regulatory or compliance experience, preferably within a managed care organization or health plan.
- At least 3 years of leadership experience with direct responsibility for compliance functions.
- Experience reviewing, analyzing, and operationalizing CMS HPMS memos, CMS guidance, state regulatory documentation, notices, bulletins, and related compliance requirements.
- Experience developing and tracking implementation plans in response to CMS, HPMS, and state regulatory guidance.
- Experience with risk management, auditing, monitoring, internal controls, and delegated entity oversight.
- CMS claims experience preferred, including familiarity with claims compliance, claims timeliness, payment accuracy, denial requirements, and CMS reporting expectations.
- Finance-related compliance oversight experience preferred, including familiarity with financial reporting, solvency-related documentation, regulatory filings, and compliance support for finance operations.
- CMS utilization management experience preferred, including knowledge of organization determinations, prior authorization, medical necessity review, timeliness standards, and CMS UM requirements.
- SNP experience preferred, including familiarity with Model of Care requirements, care coordination, HRAs, ICPs, ICTs, and SNP-specific CMS expectations.
- Quality experience preferred, including knowledge of quality improvement activities, performance monitoring, member experience, and health plan quality initiatives.
- Star Ratings experience preferred, including familiarity with CMS Star Ratings measures, performance improvement efforts, data monitoring, and cross-functional coordination to support improved outcomes.
- Certified in Health Care Compliance preferred, or ability to obtain certification within 12 months of hire.
- Strong knowledge of CMS regulations, Medicare Advantage, Part D, HPMS communications, and applicable state regulatory requirements.
- Experience with compliance auditing, training, policy development, corrective action plans, investigations, regulatory reporting, and implementation of regulatory changes.
- Proficiency in Microsoft Office, including Word, Excel, PowerPoint, and SharePoint.
- Strong research, analytical, organizational, written communication, and verbal communication skills.
- Ability to work on-site daily at the company’s Huntington Beach, California office location.
Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!
Job Type: Full-time employment
Location: Huntington Beach, CA
Compensation Range:
$100,000 – 150,000 annually
Actual compensation offered will be determined based on experience, qualifications, skills, internal equity (if available), and geographic location. This position may also be eligible for performance-based incentive compensation and benefits.
Benefits:
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401(k)
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Paid time off (vacation, holiday, sick leave)
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Health insurance
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Dental Insurance
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Vision insurance
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Life insurance
Schedule:
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Full-time onsite (100% in-office)
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Hours of operations: 9am – 6pm
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Standard business hours Monday to Friday/weekends as needed
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Occasional travel may be required for meetings and training sessions.
Ability to commute/relocate:
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Reliably commute to the required office location, or planning to relocate before starting work.
PHYSICAL DEMANDS
Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.
- Other duties may be assigned in support of departmental goals.
