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Humana NABA Senior Compliance Professional in Jersey City, New Jersey

Description

The Senior Compliance Professional will provide guidance for the development and implementation of Humana's Oklahoma Medicaid Compliance Program. He/she will serve as the primary point of contact for all Managed Care Organization (MCO) communications regarding compliance issues. He/she will ensure that written policies, procedures, and standards are in compliance with requirements set forth in the Contract. He/she will analyze business requirements, provide research and regulatory interpretation, and advise internal business units and external business partners in delivering results in a manner that minimizes compliance risk exposure for the Company.

Responsibilities

The Senior Compliance Professional will provide guidance for the development and implementation of Humana's Oklahoma Medicaid Compliance Program. He/she will serve as the primary point of contact for all Managed Care Organization (MCO) communications regarding compliance issues. He/she will ensure that written policies, procedures, and standards are in compliance with requirements set forth in the Contract. He/she will analyze business requirements, provide research and regulatory interpretation, and advise internal business units and external business partners in delivering results in a manner that minimizes compliance risk exposure for the Company.

While working within assigned areas to optimize business results, you will:

  • Maintain key relationships both internally with Humana operational leaders as well as externally with our business partners, the State Medicaid Office and/or the Centers for Medicare and Medicaid Services (CMS)

  • Interpret and define regulatory and contract requirements to be implemented by appropriate Humana Departments and/or external business partners;

  • Provide on-going oversight and monitoring of all Medicaid business operations to ensure full compliance and minimize risk for the Enterprise;

  • Review and analyze market documents and data to identify what can be used to evidence meeting regulatory standards;

  • Work across Humana operational units and product lines to enhance data analytics and operational improvement efforts

  • Coordinate and manage a standard set of data relating to regulatory standards

  • Perform risk assessments, develop and oversee action plans, and provide guidance to operational groups;

  • Serve as a translator between Humana business leaders and State and Federal Medicaid Departments assisting with the interpretation of the intention of the guidelines;

  • Coordinate day-to-day interaction with outside regulators as necessary;

  • Act as a key participant in both on and offsite external audits, working with the regulators, as necessary.

Required Qualifications

  • Bachelor's degree in related field

  • Advanced experience working in a Compliance-related or managed care-related field

  • Experience working with regulatory agencies, including state departments of health insurance and/or CMS

  • Knowledgeable in process improvement and metrics development

  • Knowledgeable in regulations governing health care industries

  • Strong communication skills

Preferred Qualifications

  • Juris Doctor or Masters of Business Administration

  • 3 plus years of experience in Health Plan Compliance or Health Plan Operations

Additional Information

Scheduled Weekly Hours

40

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