Director Medicare Rac Audit Jobs (NOW HIRING)

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy.AZ Blue offersa variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:

• Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week

• Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week

• Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month

• Onsite: daily onsite requirement based on the essential functions of the job

• Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

Responsible for ensuring overall compliance with all Corporate and Medicare compliance activities and programs. Serves as the Medicare Compliance Officer and is the primary point of contact for the Centers for Medicare and Medicaid Services (CMS) for Medicare products.

REQUIRED QUALIFICATIONS

Required Work Experience

• 5+ years of management experience
• 7+ years of experience in corporate compliance
• 5+ years of experience in Medicare Advantage program compliance

Required Education

• Bachelor’s Degree in business, healthcare policy, judicial studies, ethics or related field

Required Licenses

• N/A

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

• Experience serving as Medicare Compliance Officer
• Experience leading CMS program audit readiness and response
• Experience with FDR oversight and delegated entity compliance
• Experience presenting to executive leadership, compliance committees, and governing boards
• Experience managing compliance issue investigations, corrective action plans, and regulatory reporting

Preferred Education

• Master’s Degree in business, healthcare policy, judicial studies, ethics or related field

Preferred Licenses

• N/A

Preferred Certifications

• CHC, CHPC, or similar certification

• Develops and/or maintains the comprehensive Medicare Compliance Programs and Work Plans for the organization, including responding to all compliance questions or concerns; developing and distributing compliance training programs for the organization’s employees, and First Tier, Downstream and Related Entities (FDRs)
• Reports to the MediSun Board and other appropriate committees on the activities of the Medicare Compliance Program
• Acts as compliance liaison for Medicare products with the Centers for Medicare and Medicaid Services (CMS), maintaining a positive relationship with the CMS Account Manager/Regional Office
• Prepares for and responds to CMS and other external audits.
• Chairs various Medicare Compliance committees for appropriate oversight
• Manages Medicare Program requirements, such as Health Plan Management System (HPMS) submissions.
• Evaluates and communicates the impact of regulatory changes and CMS guidance on Medicare compliance program requirements.
• Oversees internal, initial and final compliance review reports. Maintain records of compliance investigation activity and track to ensure all work papers within each investigation or review are accurately controlled.
• Oversees identification, assessment, monitoring, and reporting of Medicare compliance risks and emerging regulatory requirements.
• Oversees development, implementation, and monitoring of corrective action plans arising from compliance reviews, audits, investigations, and regulatory findings.
• Monitors quality performance measures, develops and maintains effective workflows, and seeks to maximize system efficiencies.
• Oversees day-to-day departmental administration and personnel by coaching and motivating departmental personnel to make maximum use of experience and skills.
• Participates in strategic planning activities and contribute to departmental and cross-functional teams to achieve BCBSAZ goals and ensure future success.
• Conducts performance evaluations, identifies and coordinates training needs, and makes determinations regarding disciplinary actions.
• Maintains effective working relationships to ensure teamwork in achieving corporate goals.
• Consults and coordinates with various internal departments, external Blue Plans or business partners and government agencies where appropriate.
• Supports enterprise compliance initiatives and provides leadership for assigned corporate compliance activities, monitoring, investigations, training, and reporting.
• Perform all other duties as assigned.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. This position currently requires 2 days in office and 3 remote workdays.

REQUIRED COMPETENCIES

Required Job Skills

• Intermediate PC proficiency.
• Intermediate proficiency in spreadsheet, database and word processing.
• Organizational skills and strong logical thinking ability

Required Professional Competencies

• Maintain confidentiality and privacy.
• Communicate professionally to both internal and external customers.
• Analyze and research data, propose solutions to resolve issues.
• Establish, contribute and maintain a positive and productive work environment.
• Ability to plan, organize and manage the work of all assigned personnel.
• Ability to collaborate and think globally.
• Must possess strong interpersonal skills, as well as effective oral and written communication skills.

Required Leadership Experience and Competencies

• Ability to optimize resources to ensure a cost effective operation. Includes proactively planning to move staff from one role to another as staffing needs, business priorities or workload changes.
• Ability to build efffective teams.
• Ability to implement new processes and procedures.
• Ability to persuade and instill effective cooperation and compliance. Develop rapport and facilitate cooperation, as well as apply corrective actions.

PREFERRED COMPETENCIES

Preferred Job Skills

• Ability to establish and maintain professional relationships with community and professional groups which reflect favorably for the department and BCBSAZ.

Preferred Professional Competencies

• Ability to coordinate activities of several departments to resolve issues.

Preferred Leadership Experience and Competencies

• N/A

Our Commitment

AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com.