CareFirst Careers

Delegated Oversight Manager

Resp & Qualifications

PURPOSE:
This role manages vendor and vendor compliance programs, including program integrity for the Government Programs division. Ensures plan is in compliance with government contract and regulations. Conducts risk assessments, internal and external audits and investigations. Reviews the vendor compliance program and program integrity program for CMS, state regulatory bodies and delegated vendors.

ESSENTIAL FUNCTIONS:

  • Ensures compliance with policies and procedures and governmental/accreditation regulations for Medicaid and Medicare Advantage Vendors.  Assist with conducting investigations of compliance violations.  Responsible for managing the day to day governance process around contracting and reporting on vendor performance metrics and issue resolution.

 

  • Assist with the development of compliance policies impacting vendors for review and approval by leadership and ensure regular policy review and consistency with contractual and regulatory requirements as well as corporate standards for Medicaid and Medicare Advantage vendors.  Significantly involved in the Vendor Management Committee process including meeting elements as well as identification and escalation of critical vendor issues.

 

  • Ensures timely completion of risk assessments and related activities for Medicaid and Medicare Advantage vendors as well as identifying potential areas of compliance.privacy vulnerability and risks.  Recommends and supports the drafting of policies/procedures for the resolution of compliance/privacy, legal, and information security issues and escalates as appropriate.

 

  • Works with business owners, Legal, TPMR, Information Security and Compliance to ensure that compliance/privacy guidance and education programs for vendors as appropriate have been developed.  Support participation in these trainings as appropriate.


QUALIFICATIONS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level: Bachelor's Degree

Education Details:  Business Administration or health related field

Experience: 5 years healthcare experience, including progressively responsible experience in compliance, program integrity, or business management.

In Lieu of Education: In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Knowledge, Skills and Abilities (KSAs)
Knowledge of healthcare compliance and privacy regulations and laws, Medicaid managed care, CMS billing rules, and OIG projects.
Strong knowledge of all standard coding sets under HIPAA.
Written and oral communication skills to effectively convey complex and detailed concepts to a diverse audience, including senior level stakeholders.
Ability to work independently and make recommendations and decisions autonomously.
 

Department

Department: Medicare Advantage MD - Shared Services

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: www.carefirst.com/careers

Closing Date

Please apply before: 10/15/21

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.

PHYSICAL DEMANDS:

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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