Job Details

Central Coast Salary Range - $117,904 - $176,857

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

The Medicare Compliance Manager plays a key role within the Compliance Division, reporting directly to the Regulatory Compliance Director. This role is responsible for providing leadership and guidance of CenCal Health's compliance program, ensuring adherence to regulatory requirements, industry standards, and organizational policies for Medicare, Medi-Cal, and Knox Keene. The Medicare Compliance Manager possesses a deep knowledge of Medicare regulations, strong leadership skills, and a commitment to promoting a culture of compliance throughout the organization.

Duties and Responsibilities

• Co-develop, implement, integrate, and manage the Medicare compliance program, ensuring it aligns with regulatory requirements and industry best practices. Ensure integration of the Medicare compliance program with CenCal Health's existing compliance framework.
• Provide guidance and leadership to cross-functional teams involved in Medicare, Medi-Cal, and Knox Keene compliance activities, including but not limited to Legal, Operations, Clinical, and Quality Assurance teams.
• Collaborate with the Regulatory Compliance Department to maintain compliance with CMS, DHCS, and DMHC requirements, including CenCal Health's Knox Keene license and contractual obligations with regulatory agencies.
• Collaborate with the Audits, Monitoring, and Oversight (AMO) Department within the Compliance Division to conduct regular assessments and audits of Medicare processes, systems, and documentation to identify compliance risks and areas for improvement.
• Collaborate with the Audits, Monitoring, and Oversight (AMO) Department and internal stakeholders to address compliance issues, develop corrective action plans, and monitor progress towards resolution.
• Responsible for daily monitoring of CMS's Health Plan Management System (HPMS), required DHCS reporting, DMHC filings, and other required regulatory submissions.
• Responsible for ensuring that all required CMS, DHCS, DMHC and other regulatory reports, including any required attestations, are submitted within required timeframes.
• Co-develop for Medicare and D-SNP and integrate with the current process for communicating regulatory information in a clear and concise manner and implementing solutions to support internal and external operational and compliance activities.
• Consult on investigations for any incoming compliance complaints of potential non-compliance. Collaborate with Security, Privacy and Fraud Prevention Office (SPF) regarding potential Fraud, Waste and Abuse, as needed.
• Partner with SPF to ensure that the DHHS OIG and Government Services Administration ("GSA") exclusion lists have been checked with respect to all employees, governing body members, and FDRs monthly and coordinating any resulting personnel issues with the sponsor's Human Resources, Security, Legal or other departments as appropriate.
• Keep abreast of changes in Medicare, Medi-Cal, and Knox Keene regulations, guidance, and enforcement priorities.
• Co-develop and implement training programs and educational materials on Medicare, Medi-Cal, and Knox Keene compliance topics to employees at all levels of the organization. New training programs should integrate with the organization's training program.
• Participate in compliance-related committees, working groups, and initiatives to promote a culture of integrity, ethics, and compliance.
• Supervises Compliance staff, with duties including but not limited to overseeing job performance, prioritizing and assigning work-related tasks, and training new staff, as necessary.

• In-depth knowledge of Medicare regulations, including but not limited to Medicare Advantage (Part C), Prescription Drug Plans (Part D), and Medicare fee-for-service (Parts A and B), as well as Medi-Cal and Knox Keene requirements.
• In-depth knowledge of health care compliance programs and how to implement and maintain the OIG's seven elements of a compliance program.
• Strong leadership and management skills, with the ability to influence and collaborate effectively across functional areas and levels of the organization.
• Excellent communication and interpersonal skills, with the ability to convey complex regulatory concepts clearly and concisely to diverse audiences.
• Analytical mindset with the ability to identify compliance risks, develop mitigation strategies, and monitor effectiveness of controls.
• Commitment to upholding ethical standards, integrity, and professionalism in all aspects of compliance-related activities.

• Bachelor's degree in Healthcare Administration, Business Administration, Legal Studies, or a related field or an equivalent combination of education and experience.
• Advanced degree (e.g., JD, MPH, MBA) preferred.
• Minimum of 5 years of experience in healthcare compliance, with a focus on Medicare compliance and regulations.
• Certification in Healthcare Compliance (CHC), Certified in Healthcare Privacy and Compliance (CHPC), or similar credentials are strongly preferred.