CareFirst Careers

Medicare/Medicaid Compliance Director

Resp & Qualifications

PURPOSE: As a member of the Federal and Consumer Government Programs (FSCGP) leadership team, the position of Director, Medicare/Medicaid Compliance is accountable for directing all aspects related to the design and execution of training curriculums, quality assurance programs and the overall state of compliance for the Medicare, Medicare Advantage and Medicaid products. Works closely with operational teams, Corporate Compliance, Mandates and Legal departments to resolve complex issues with inter-related legal and Medicare and/or Medicaid compliance aspects. This position will direct all aspects related to the design and execution of Medicare and Medicaid compliance training programs through education, training, investigation activities and the detection of possible violation of the federal and state statutes, regulations or contractual terms impacting Medicare and Medicaid programs. Additionally, this position will be responsible for the start-up phase evaluation of operational compliance. In fulfilling the duties of this position, the Director, Medicare/Medicaid Compliance, will be responsible for ensuring training curriculums and quality assurance programs are in compliance with the contract between CareFirst and The Centers of Medicare and Medicaid Services (CMS). Additionally, the incumbent will create and maintain an effective compliance program that meets the seven core requirements and and fosters a culture of compliance.

Under the direction of the Senior Vice President, Federal & State Consumer Government programs the principle duties and accountabilities include, but are not limited to, the following:

1. Compliance/Audit:

  • This position has direct accountability for establishing an effective compliance program based on the seven core elements of compliance. Directs the activities related to the design, development, implementation and maintenance of compliance and quality assurance programs across all major functional areas and vendors for Medicare and Medicaid within the FSCGP division.Ensures internal departments understand and implement CMS and applicable state rules, policies and regulations. Responsible for delegated oversight and risk assessment activities for internal departments and first tier, downstream and related entities.
  • Collaborates with Corporate Compliance to support all Medicare audits, reviews and examinations conducted by internal audit staff.  Directs and oversees internal Medicare risk assessments, to ensure that appropriate staff are fully aware of objectives and that they can produce and maintain suitable records, reports, and files which adequately document planning, execution, and reporting for all relevant activities pertaining to the regulations, including documentation and storage of policies and procedures.  Develops and implements internal compliance monitoring procedures.  Ensures conclusions, findings and recommendations for improvement or corrective action are appropriately presented to management staff for review, and verify that all findings are accurate, complete and objective. 
  • Maintains a database of Medicare regulatory requirements and status of compliance that is auditable and trackable.  Works with FSCGP leadership to ensures non-compliant activities are corrected and all compliance related changes are tracked. Monitors, assesses and reports significant matters to senior management. Point of contact for Corporate Compliance, Legal and Mandates teams to manage compliance of operational teams with the FSCGP division.

2. Training:

  • Directs a staff of training professionals in the design, development, presentation and evaluation of effective, appropriate and progressive training programs in collaboration with Corporate Compliance Office and Legal.
  • Participates in and develops training and education regarding Medicare and Medicaid Compliance throughout the business unit including the development of electronic learning devices, if applicable, in concert with, if applicable, corporate audit, HRD and the Corporate Compliance Office.  Ensures that all Medicare and/or Medicaid requirements for training are met by internal departments and first tier, downstream and related entities.. 
  • Directs the activities resulting in uniform, compliant methods and practices for executing daily activities in order to measure and improve associate skills that have a direct effect on customer satisfaction.
  • Provides guidance on changes to the law that may impact training and education and require updates to Medicare and/or Medicaid Compliance training programs. 

3. Quality:

  • Directs all activities related to the quality of performance of the SBU. Ensures that associates receive detailed, clear and professional performance feedback, in adherence to CareFirst Policies, SOPs and business protocols. Independently validates performance through focused audits and controls.
  • Develops individual performance measures that support customer satisfaction initiatives. Additional quality assurance responsibilities include the development of uniform methods and practices (quality assurance programs) in order to measure and improve associate skills and systems performance. 

4. Communication:

  • Prepares status reports communicating compliance activities, identification and correction of problems, trends identified, recommendations and analysis of effectiveness fo the Medicare and Medicaid Compliance programs to the Senior Vice President of FSCGP.
  • Collaborates with the Medicare and Medicaid Compliance officers, as well as the Corporate Compliance team to assure that compliance activities across the organization meet federal, state and organization standards.
  • Direct the management and execution of the FSCGP Disaster Recovery Program.
  • Participates in Enterprise Risk Management activities with Enterprise Risk Management and the Corporate Compliance Integrated Risk Management teams.
  • Interface with Executive Leadership, Corporate Finance, Strategic Marketing, Government Affairs, Medical Affairs, IT, Strategy & Planning, Human Resources, Legal, Internal and External Audit, Procurement, Vendors and the Blue Cross and Blue Shield Association.

SUPERVISORY RESPONSIBILITY: This position’s direct reports includes up to four Managers and total of 4-6 direct reports. Provides oversight of 20+ indirect reports.

COMPETENCIESThis position requires the following competencies to perform at a superior level:
Conceptual Grasp/Managing Change: Effectively copes with change and isn’t upset with vague situations; comfortably shifts focus and handles risk and uncertainty

Problem Solving:  Strategic thinking, facilitating, negotiating, conflict management, influence, coaching, empowerment, delegation, problem solving, planning, teamwork development. 

Business Acumen: A basic understanding of business processes and financial control procedures, methods and philosophies coupled with strong analytical reasoning, and problem-solving skills are highly desired. Drive, commitment, self-confidence, insight, judgment, integrity, ethics, continuous personal improvement, responsiveness, timeliness, learning capacity, flexibility and adaptability, ability to meet deadlines.

Effective Commnication/ Building Relationship:  Individual must possess strong communication skills, and must be able to effectively present complex information both orally and written.  Individual must be team oriented and demonstrate flexibility in terms of moving freely from one project to another.

Integrity:  Exercises high standards of business conduct; is trustworthy, is intellectually honest; lives the values of the organization


Bachelor’s degree required, graduate degree preferred, 5 years leadership experience plus 7- 10 years of progressively responsible corporate compliance, Medicare or government work experience and/or related experience, inclusive of at least 5 years Medicare Part C compliance experience.

Qualified candidates should have demonstrated experience in designing, developing and implementing organizational programs and initiatives that focus on increasing quality, productivity and customer satisfaction.  Experience in developing and designing performance management and continuous improvement systems to align with corporate and divisional goals and objectives is a must.  Must have the ability to manage multiple priorities, meet project goals and deadlines and coordinate and integrate processes and procedures to ensure consistency across the division. Ability to effectively communicate orally and in writing, develop and deliver large group presentations, and design, generate and analyze reports for Senior Management is required.  Must be capable of developing partnerships and relationships with internal and external colleagues, clients and vendors to ensure that operations programs are aligned with corporate and strategic objectives.  Experience in establishing benchmarking and best practice research processes is a plus.

Must be able to effectively work  in a fast-paced environment with frequently changing priorities, deadlines,  and  workloads that can be variable  for long periods of time.  Must be able to meet established deadlines and handle multiple customer service demands  from internal and external customers, within set expectations for service excellence.   Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.



Department: Federal & State Consumer Government Programs

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 10/11/2019

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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