CareFirst Careers

Medicare Compliance & Regulatory Oversight Consultant

Resp & Qualifications


  • This position reports directly to the Director of Medical Affairs Compliance & Regulatory Oversight, solely supporting Medical Affairs and is accountable for managing all aspects related to the overall state of Compliance & Regulatory Oversight for the Medical Affairs Division functional areas assigned.
  • This position is directly accountable for ensuring the integrity of the Compliance, Regulatory and Audit process for Medical Affairs.  This position has the responsibility for evaluating and maintaining compliance and audit protocols for the Medical Affairs division functional areas assigned in coordination with Corporate Compliance, Corporate Audit & Assurance Services (CAAS), Sarbanes Oxley, MTM and Legal. Reporting directly to the Compliance Director of Medical Affairs to manage the activities related to the design, development, reporting and oversight of compliance program to ensure that each functional area within Medical Affairs, as assigned, remains in compliance and alignment with Federal and State regulatory requirements and mandates, as well as corporate and divisional goals and requirements. 
  • Works to ensure that each functional team, assigned, within Medical Affairs incorporate criteria needed to monitor regulatory compliance in each functional area. Maintains documentation and reporting of evidence of compliance / policies and procedures. Regularly monitors and controls correction action plan implementation and communicates risks associated with the control deficiencies identified to all stakeholders.

PRINCIPAL ACCOUNTABILITIES: Under direction of Director, Medical Affairs Compliance and Regulatory Oversight, the incumbent’s accountabilities include, but are not limited to the following:

Compliance Program Management
• Supports the implementation and manages the Medical Affairs Compliance program to ensure compliance and alignment with Federal, State regulatory statutes.
• Supports the development and manages a compliance program to effectively implement, revise and test controls and continuously reviews and improves departmental policies and procedures to achieve greater efficiencies and effectiveness.
• Provide interpretation of regulations and regulatory rules/guidelines to demonstrate Medical Affairs and its delegated entities comply with state and federal standards.  With regard to compliance-related policies, the Manager will gather and organize applicable insurance laws and regulations (mandates) into a central content repository and ensure that a department policy, procedure and audit criteria to measure compliance exists for laws/regulations. 
• Continuously analyzes and aligns functional area policies, procedures, SOPs, workflows, and systems and ensure they comply and align with regulations and remain updated and current. 
• Reviews complex business processes, systems, workflows, SOPs and policies, procedures to identify, document, and elevate the presence of risks and trends within, that may be non-compliant with contracts and or statutory requirements.
• Works directly with the division’s Training teams to ensure training content incorporates necessary procedures, SOPs, workflows, etc. applicable to the policies.
• Reviews and makes recommendations for workforce management related to productivity and overtime. 
• Reviews and audits internal controls, both manual and automated, and/or manage controls in each functional area to remove any risk or exposure. 
• Analyzes and audits controls for strengths and weaknesses and ensures that special focus is allocated to the specific risk areas creating the highest exposure to the division.  
• Support Audits and manages the activities related to reviewing audit findings with stakeholders.
• Works with division’s management to establish and implement corrective action plan as an outcome of any audit findings.
Monitoring and Reporting
• Regular monitoring and control of corrective action plan implementation and communication/reporting of risk associated with the control deficiencies identified to all stakeholders.
• Actively participate in implementation/corrective workgroups to ensure compliance perspective and concerns are addressed through the process.
• Acts as a liaison across all areas internally including of Medical Affairs, Corporate Audit, Corporate Compliance, Finance, and Legal.
• Provide regular investigative, analytic and audit reporting data to stakeholders.
• Ensure documentation is developed and maintained to support progress of projects. Drives the development of workflow process to manage the impact of various projects on multi-departmental workforces and their daily activities.
• Monitors, assesses, and reports significant matters to senior management.
• Keeps abreast of emerging issues and developments that have direct impact on the division.
• Oversees daily, weekly, and quarterly progress updates of all projects and data when necessary.
Matrixed leadership
• Directs, coaches and leads other colleagues across the Medical Affairs division in a matrix approach in day to day compliance and regulatory activities.  Helps to define and support the direction and vision for policy and quality standards for all departmental work; leads tactical planning, implementation, monitoring and reporting; budget and expense planning; provides ad hoc executive management reporting.
• Ensures compliance for CareFirst compliance responsibilities.  Submits departmental regulatory filing and reports by the associated statutory deadlines.  Operates department within the expected Federal and State legal and regulatory requirements. 



·        Bachelor’s degree in a healthcare or business-related field. In lieu of a Bachelor’s degree, must have at least 4 years of industry related experience

·        Experience with CMS Programs – Medicare, Medicare Advantage, and/or Medicaid


 o   Insurance company and Health plan experience

In addition:
• Must have at least 5 years of experience in the health care industry and a minimum of 3 years management experience. Must be generally conversant with the laws, regulations and guidelines affecting CareFirst
• Demonstrated ability to plan, direct and manage compliance and regulatory related activities to ensure the achievement of corporate and divisional goals
• Experience in complex/analytical regulatory compliance
• Experience in Compliance monitoring, Audits, project management, business process analysis, work flow, and task analysis
• Flexibility and the ability to work under time constraints, adapt to shifting priorities, to work independently as well as part of a team are required.
• Ability to present and discuss regulatory compliance goals in a way that establishes rapport, persuades others, and gains commitment
• Ability to research complex issues, interpret regulations and regulatory rules/guidance, and exhibit sound judgment in determining a recommendation or solution to a problem.
• Ability to interact effectively with people at different organizational levels, both internally and externally and build and maintain relationships within the company and in the community 
• Strong interpersonal skills: ability to work and make decisions independently and in a team environment
• Incumbent must display leadership qualities, functional expertise, and business perspective
• Ability to gather and analyze data and generate reports
• Strong problem-solving abilities
• Excellent planning, organizational skills
• Proficient in computer software applications
• Thorough knowledge of medical terminology
• Self-directed with ability to work independently and make decisions in a changing environment
• Excellent oral and written communications; able to communicate and make presentation to all levels of management and associates at all levels throughout the Company
• Must demonstrate resilience and 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.
Understanding of legal requirements and expectations for health insurance operations



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: 2/2/2020

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

Learn more about Medical Management