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Position Summary
Senior level compliance position that is responsible for the management, execution, and oversight of the compliance program activities and deliverables of a Medicaid managed care organization operating in a highly complex regulatory environment. Oversees the activities of other compliance team members assigned to the market. This position is responsible for developing and maintaining systems and processes that demonstrate the principles of an effective Compliance program and promote compliant and ethical behavior in the assigned Medicaid health plan. Responsibilities include, but are not limited to:
Serve as the designated Compliance Officer for Aetna’s IL Medicaid health plan
Acts as the primary liaison to the state Medicaid agency, facilitating compliance and contract-related communications and activities.
Facilitates the preparation for and management of external audits conducted by state Medicaid and related agencies or partners (including the completion of quality reviews prior to submission) in conjunction with health plan leadership through final report and corrective action plan closure.
Lead and execute all elements of the Medicaid compliance program for Aetna’s IL Medicaid health plan.
Conduct research and develop recommendations to help develop compliant business operations, processes and policies in accordance with state specific Medicaid program requirements.
Develop compelling, strategic, and appropriate compliance related communications on behalf of the health plan in response to state Medicaid agency inquiries or requests.
Maintain an in-depth working knowledge of the health plan’s contractual, regulatory, and program policy related obligations as a Medicaid managed care organization and serve as a resource to health plan and growth partner staff for education, training, and business decision making purposes.
Ensure that current resource tools and other internal deliverables such as current contract library, regulatory reporting assignments, risk assessments, risk tracking lists, internal reporting systems and summaries, and other department wide tools are current and accessible to business partners to ensure the appropriate monitoring and oversight of health plan compliance processes.
Utilize systems unique to job functions, including standard-issue software such as Microsoft products and compliance specific tools such as Archer; maintain system documentation, serve as subject matter expert, train users of system, contribute to system design, oversight or maintenance.
Lead and direct oversight and monitoring activities to evaluate levels of compliance with new and existing Medicaid managed care organization requirements across the business; support business partners in the development of mitigation and corrective action plans and effectively escalate risks, concerns and other issues through appropriate channels.
Maintain positive, productive relationships with internal and external senior level constituents to effectively communicate and influence ethical and compliant outcomes.
Oversee the submission of required regulatory reports (standard and ad hoc), including the completion of high level quality reviews prior to submission and the maintenance of tracking systems and tools to document ownership, reporting requirements, and monitor timely delivery and acceptance of reports.
Provide training and guidance to less experienced team members to accomplish goals.
Other duties as assigned.
Required Qualifications
• 10+ years of previous experience in Medicaid or Medicaid managed care.
• 5+ years of roles that required use of project management skills and responsibilities.
• 2+ years of previous management experience.
Preferred Qualifications
Audit experience.
Master’s degree in Public Policy, Health Care Administration, Public Administration or similar fields or a law degree.
Education
Bachelors degree required or equivalent years of related experience.
Pay Range
The typical pay range for this role is:
$100,000.00 - $231,540.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Skills Required
- 10+ years of previous experience in Medicaid or Medicaid managed care.
- 5+ years of roles requiring project management skills and responsibilities.
- 2+ years of previous management experience.
- Bachelor's degree or equivalent years of related experience.
- Experience using Microsoft products and compliance tools such as Archer.
- Ability to serve as the designated Compliance Officer and liaise with state Medicaid agency.
- Maintain in-depth knowledge of Medicaid contractual, regulatory, and program policy obligations.
- Audit experience.
- Master's degree in Public Policy, Health Care Administration, Public Administration or law degree.
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
