[Hiring] Manager Medicare Compliance @St. Joseph Hospital & Medical Center

Role Description

The Medicare Compliance Officer (MCO) is responsible for developing, implementing, and overseeing the compliance program for Medicare Advantage (Part C) and Medicare Part D activities for Mercy Care Plan, managed by Aetna, a CVS Company. This role ensures adherence to all applicable federal and state regulations and CMS requirements, safeguarding the integrity and compliance of Plan operations.

• Maintain day-to-day operational alignment with the Mercy Care Medicare team.
• Hold direct reporting accountability to the Chief Executive Officer (CEO) and the Audit and Compliance Committee of the Mercy Care Plan Board of Directors.
• Provide formal reports to the Board of Directors, CEO, and Compliance Committee at least quarterly, detailing:
  • Status of Mercy Care Plan’s Medicare Compliance Program implementation.
  • Identification and resolution of compliance issues.
  • Oversight and audit activities.
• Oversee the development and administration of the Board of Directors’ annual Code of Conduct and compliance training program, including:
  • Program design.
  • Content creation.
  • Distribution.
  • Tracking.
  • Ongoing maintenance to ensure full compliance with regulatory and organizational standards.
• Develop and implement programs that promote a culture of integrity by encouraging reporting of suspected fraud, waste, abuse, or other misconduct.
• Respond promptly to reports of potential Medicare fraud, waste, or abuse (FWA), including:
  • Coordinating internal investigations.
  • Developing appropriate corrective or disciplinary actions when necessary.
• Maintain the FWA reporting mechanism and collaborate closely with the Internal Audit Department and the Special Investigations Unit (SIU).
• Exercise flexibility in designing and managing internal investigations and implementing corrective measures.
• Coordinate with the Plan’s Human Resources department to ensure thorough screening of the DHHS OIG and GSA exclusion lists for all employees, officers, directors, managers, and contracted entities.

Qualifications

• Bachelors or an equivalent combination of directly related work experience and/or education.
• Five (5) years of experience that demonstrates solid Medicare compliance program development, operation, and administration responsibilities.

Requirements

• Registered Nurse: AZ (preferred).
• Strong business acumen and healthcare industry knowledge.