Centene Corporation Director, Ethics & Compliance in Raleigh, North Carolina
You could be the one who changes everything for our 26 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose: Develop and implement strategies to ensure successful maintenance and implementation of compliance programs that meet regulatory requirements for assigned products across the entire company
• Conduct compliance audits, write corrective action plans and collaborate with various departments to ensure timely completion and compliance with local, state and regulatory requirements
• Provide oversight of the compliance function at the health plans, including accurate and timely communication to various departments and coordination of policy development
• Oversee the investigation of suspected fraud within the health plans and report to management and regulatory entities
• Assist management with enforcement and discipline in appropriate instances of non-compliance
• Inform health plan’s Board of Directors of status and activities pertaining to compliance
Commercial Insurance (additional responsibilities):
• Ensure entity licensures are obtained and maintained in accordance with federal and state requirements
• Coordinate with various departments to ensure changes from the state are reflected in premium rates and benefits
Medicare (additional responsibilities):
• Ensure CMS and state requirements and expectations are met accurately and timely
• Oversee, administer and implement various aspects of the Medicare compliance program, including HIPAA and fraud, waste and abuse (FWA)
• Identify, evaluate and analyze the impact of CMS and Medicare regulatory issues and advise management concerning impact
• Monitor the FDR oversight program to ensure all Medicare and MMP plans are conducting appropriate oversight
• Report all Medicare and MMP risks in accordance with risk reporting policies
• Provide required ethics, compliance, risk management, FWA, privacy and security training to all employees and non-employees as needed
• Ensure that state or federal regulatory requirements related to business continuity and disaster recovery are communicated and met
• Monitor all CMS and state communications through the health plan management system (HPMS) and ensure changes are made and issues are addressed
• Serve as the primary MMP Compliance Officer for designated state(s) including the Integrated Care Delivery System MMP program
o Serve as the primary point-of-contact for all MMP operational issues
o Oversee all communication between the state/federal government and health plan
o Coordinate and track all contract deliverables
o Field and coordinate responses to state and federal inquiries and complaints
o Coordinate the preparation and execution of contract requirements, random and periodic audits, and site visits
Education/Experience: Bachelor’s degree in Business Administration, related field or equivalent experience. 7+ years of combined compliance program management and contract experience with state Medicaid, Medicare or commercial programs, including internal and state audits. Experience with healthcare regulatory agencies in the development of compliance and fraud programs preferred. Experience with oversight of implementation of federal and state insurance or program requirement preferred.
Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
TITLE: Director, Ethics & Compliance
LOCATION: Various, North Carolina
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