Government Programs Compliance Specialist, Senior

Your Role 

The Medicare Compliance team is responsible for providing oversight of Blue Shield’s Medicare Advantage and Part D plan operations to help ensure compliance with CMS regulations, contractual requirements, and internal policies. The Government Programs Compliance Specialist, Senior will report to the Senior Manager, Government Programs – Medicare Compliance. In this role, you will help support the effectiveness of the Medicare Compliance Program through risk-based monitoring, audits, and compliance activities that include evaluating the accuracy, completeness and integrity of plan materials, identifying compliance risks, and partnering with business teams to promote regulatory compliance and corrective action.  

Your Work 

In this role, you will: 

• Perform regulatory compliance reviews of Medicare Advantage and Part D plan member and marketing materials and (as required) submit materials to the Centers for Medicare and Medicaid Services (CMS) and the Department of Health Care Services (DHCS).

• Document final compliance solutions, identified risks, and mitigation plans in a controlled document.

• Monitor implementation of corrective action plans to ensure remediation activities are on track, risks are identified, and mitigation plans are developed; escalate issues to department management as appropriate.

• Summarize and distribute low to complex federal and state updates to impacted business areas.

• Provide day-to-day support to business areas that support Blue Shield’s Medicare Advantage and Part D plans on low to moderately complex inquiries.

• Manage and maintain Medicare Compliance department activities e.g. development and maintenance of the department audit calendar, CMS, DMHC and DHCS audit calendar, department mailboxes, intranet website, policies and procedures, and other items as needed.

• Support calibration of risk and controls with business units supporting the Medicare line of business. 

• Develop, prepare, and present analyses, reports, and recommendations to department management and other stakeholders of federal and state requirements

• Participate in multiple projects or initiatives within and outside of the department.

• Other duties as assigned.

Your Knowledge and Experience 

• Requires a bachelor’s degree or equivalent experience

• Requires a minimum of 5 years of relevant experience conducting compliance reviews of Medicare Advantage and Part D plan marketing and member communication materials

• Requires a deep knowledge of the Centers for Medicare & Medicaid Services’ (CMS) compliance requirements for Medicare Advantage and Part D plan member and marketing materials, as well as the Department of Health Care Services’ (DHCS) compliance requirements for exclusively aligned enrollment dual special needs plan member and marketing materials. 

• Requires excellent organizational skills.

• Requires strong independent judgment, problem solving, critical and analytical skills, including an exceptional “moral compass” and work ethic.

• Requires ability to work collaboratively in a team, perform duties with minimal supervision, multi-task, and to deliver a quality product in a highly regulated, demanding, and constantly changing corporate environment.

• Requires proficiency in Microsoft Office suite programs (Word, Access, Excel, PowerPoint and Outlook), SharePoint, and the Health Plan Management System (HPMS). 

• Project management or similar experience is preferred

• Professional certification (CHC – Certification in Healthcare Compliance) is preferred

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. 

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. 

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!  

Our Values: 

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. 
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. 

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail. 

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.