JOB SUMMARY

The Medicare Compliance Specialist is a key member of the organization, responsible for ensuring adherence to federal, state, and local healthcare laws and regulations, as well as internal policies and procedures. This position plays a pivotal role in promoting a culture of compliance across the organization, supporting contract management, overseeing regulatory reporting, and contributing to the development and maintenance of compliance programs. 

The Medicare Compliance Specialist will monitor and interpret complex regulations, including HIPAA, CMS guidelines, Medicare Advantage, and Part D requirements, and ensure the organization's activities align with these standards. This role involves conducting audits, investigations, and risk assessments, providing guidance to address compliance vulnerabilities, and assisting in the implementation of corrective action plans.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Monitor and interpret federal, state, and local healthcare laws, including regulations related to patient privacy (HIPAA), billing and coding (CMS regulations), fraud, and abuse laws.
• Support business owners by reviewing and providing recommendations to corrective action plans (CAPs).
• Develop, review, and revise policies and procedures annually or when new regulatory guidance is issued.
• Contribute to the development and execution of the annual Compliance Work Plan and assist with internal Part C and Part D auditing and monitoring activities.
• Coordinate the collection and submission of compliance reports (monthly, quarterly, annual) for internal and external stakeholders, including the CMS Account Manager and Board of Directors.
• Assist the Chief Compliance Officer with annual risk assessments, including scoring risks and managing high-risk areas requiring audits.
• Support pre-delegation reviews of vendors, including compliance and IT security assessments.
• Develop and deliver compliance training for employees, managers, and the Board of Directors, including creating educational materials.
• Analyze and distribute CMS Health Plan Management System (HPMS) memos and instructions, ensuring actions are undertaken as required.
• Maintain current knowledge of industry changes, including Medicare Advantage, Part D compliance, and best practices.
• Provide timely filing of Part C and Part D reporting data to CMS.
• Assist with FDR auditing and monitoring activities and manage compliance with regulatory training requirements.
• Assist in compliance and fraud, waste, and abuse (FWA) investigations.
• Participate in CMS Regional Office meetings and internal management meetings, representing the Compliance Department as needed.
• Identify compliance issues, potential vulnerabilities, and risks, and implement corrective actions or improvement plans.
• Monitor compliance program performance and ensure its effectiveness by taking appropriate corrective steps.
• Maintain records and archives for compliance and risk inquiries, ensuring all required documentation is available.
• Provide support for regulatory audits, including CMS and NCDOI audits.
• Monitor and coordinate compliance activities across departments, identifying trends and supporting regulatory adherence.
• Contribute to privacy initiatives, conducting investigations and audits, and refining processes.
• Stay informed about the latest compliance developments, leveraging professional associations, conferences, and industry seminars.
• Perform all additional duties as assigned.

EDUCATION AND EXPERIENCE

Education:

• Associate or bachelor’s degree, preferably in Business, Health Care Administration, Legal, or a related field. In lieu of education, 3-5 years of direct Medicare experience

Required Experience:

• Minimum 3 - 5 years experience in the Medicare Advantage industry
• Excellent written and verbal communication skills. Ability to clearly communicate with co-workers.
• Basic math skills required, including percentages, ratios, graphing, and spreadsheet skills.
• Strong research, analysis, organizational, and interpretative skills. Requires ability to define and prioritize problems and manage workload with minimal direct supervision.

Preferred Experience:

• Experience in Legal, contracts, North Carolina State laws

Other Requirements:

• Annual Flu Vaccine

KNOWLEDGE, SKILLS, AND ABILITIES

Required Competencies:

• Working knowledge of Medicare laws and regulations affecting our business.
• Ability to make independent decisions with minimal supervision.
• Respond timely to regulatory inquiries.
• Good project management skills.
• Positive attitude.
• Strong sense of collaboration and diplomacy.

PHYSICAL REQUIREMENTS

• Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or;
• A negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.
• Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Benefits from Day One: 

• Medical, Dental, and Vision Coverage
• 401(k) Retirement Plan with Company Match
• Paid Time Off (PTO) and Volunteer Time Off (VTO)
• Paid Company Holidays
• Health Savings Account (HSA) and Flexible Spending Account (FSA) Options
• Long-Term and Short-Term Disability Coverage
• Employee Assistance Program (EAP) for Personal and Professional Support
• Tuition Assistance for Continued Education
• Pet Insurance for Your Furry Family Members
• Ongoing Professional Development and Training Opportunities
• And an array of additional benefits designed with you in mind.

ABOUT HEALTHTEAM ADVANTAGE

HealthTeam Advantage is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

HealthTeam Advantage (HTA), a Greensboro-based health insurance company, offers Medicare Advantage plans to eligible Medicare beneficiaries in multiple North Carolina counties. HTA has been named a “Best Places to Work” finalist three times by Triad Business Journal. To learn more, visit HealthTeamAdvantage.com.