Manager of Health Plan Compliance

Company Name:
Essence Healthcare
Position Type:
Join Our Growing Team
Essence Healthcare serves the people who consume care, the professionals who provide care and the organizations that manage care. Our unique health insurance business provides consumers comprehensive and affordable coverage focused on wellness and personal service. By innovating at the leading edge of reimbursement, collaboration and clinical informatics, Essence Healthcare is leading the positive evolution of health care.

Essence Healthcare(TM) offers people with Medicare comprehensive and affordable health insurance that focuses on wellness, care coordination and personal service. Essence's Medicare Advantage HMOs bundle hospital, medical and prescription drug coverage together into one plan with one affordable monthly premium, and include additional benefits not covered under the Original Medicare program.

Summary Description

The Manager of Health Plan Compliance oversees and conducts various compliance-related activities for the Company's Medicare Advantage (Part C) and Prescription Drug (Part D) health plan programs. The Manager serves as a business partner/consultant with health plan operational areas and assists in maintaining an understanding of and compliance with regulatory and legal requirements as well as the organization's internal policies and procedures. The Manager also serves as a regulatory liaison, and is the point of contact for health plan compliance matters in the absence of the CCO.
Assist CCO in monitoring and reviewing regulatory and legislative requirements and changes; responding to regulatory requests, audits, and investigations; communicating and implementing regulatory requirements; and following up with appropriate areas to ensure that required changes are implemented.
Serve as a regulatory advisor to health plan operational areas and the Compliance team; serve as liaison with regulatory authorities as needed relative to Compliance Program activities, including participation in regulatory site visits, meetings, and conferences.
Oversee the review and timely submission of accurate marketing materials, Parts C and D reporting, and data validation activities. Maintain calendar of required regulatory activities to ensure that the health plan remains current on required submissions and activities.
Work with health plan first-tier, downstream, and related entities, business associates, vendors, and other contracted parties regarding various health plan operational procedures, and any compliance matters that may arise.
Oversee and participate in the investigation of reports of health plan non-compliance, to include conducting thorough investigations, reviewing documents, data, and processes, maintaining thorough case files, and delegation of responsibility as needed to ensure proper follow-up and resolution. Ensure that reporting mechanisms are in place and accurately functioning. Promptly disclose high-risk or serious issues or findings to the CCO and/or General Counsel.
Collaborate with health plan functional leadership and staff to evaluate operating procedures, systems, and standards; identify potential or actual compliance risks; identify deficiencies and provide suggestions for resolution; and offer staff training as appropriate.
Participate in internal compliance audit and monitoring for health plan compliance with applicable laws and Compliance Program requirements. Assist business partners in interpreting audit findings, preparing and completing audit responses, and developing corrective actions as appropriate.
Develop, implement, track progress, and report on health plan compliance objectives, projects, timelines, and deliverables for the Compliance Program. Create and maintain operational dashboards, analyzing and trending data to evaluate performance in various areas.
Contribute to and participate in the Compliance Awareness, Training, and Education Program as needed to support continuous learning as well as annual mandatory compliance training requirements.
Partner with managers of other compliance program units, including Fraud, Waste, and Abuse, Audit & Monitoring, and Compliance Program Administration, contributing expertise in these areas to help fulfill overall compliance program needs and responsibilities.
Review and recommend revisions to the Health Plan Compliance Program and Compliance Policies & Procedures as appropriate to respond to changes in the Company's needs and applicable legal requirements, identified weaknesses in the Program, or identified systemic patterns of noncompliance.
Regularly report to the CCO and the Health Plan Compliance Committee on compliance matters, and assist in establishing methods to reduce the Company's vulnerability to violations of the Compliance Program.
Communicate status of operational and compliance-related projects to supervisor, internal individuals and/or teams, and to internal/external clients. Act as a facilitator and coordinator of compliance-focused issues.
Supervise, direct, and evaluate the activities of health plan compliance staff. Serve as a resource for staff and continuously cross-train to maximize knowledge, capabilities, and level of expertise.
Participate as a member of various standing or ad hoc committees within the Company.
Collaborate with the CCO, General Counsel, or other subject matter experts as necessary for any issues where it is determined that the expertise of these individuals should be consulted.
Advocate for compliance and ethics in the operation of the Company's health plan activities, delivering a clear message throughout the organization that individuals are expected and encouraged to bring any compliance concerns to the attention of appropriate authorities, and that the Company has a firm policy of non-retaliation against those who make such disclosures.
Maintain education, awareness, and knowledge of current regulations and best practices in the health care industry and in the management of health plan operations. Cross-train team members for continuous departmental improvement and strengthening of core competencies. Bring regulatory changes and matters of significance or urgency to the attention of the CCO and/or Departmental Executives and facilitate needed changes for compliance or to improve business practices.
Continuously communicate the message of compliance throughout the organization through various means, such as emails, Intranet, newsletters, compliance events, or other effective mechanisms.
Other related duties as assigned to meet departmental and Company objectives.
Bachelor's degree in business, public health administration, human resources, law, or a related field.
Certified Healthcare Compliance (CHC) designation preferred.
3 or more years experience managing a corporate compliance program in a federally regulated environment, preferably health care, including interacting with government agencies and regulators.
3 or more years experience supervising staff members.
Familiarity with operational, financial, quality assurance, and human resource procedures and regulations. Thorough knowledge of health care and/or insurance practices and procedures. Familiarity with healthcare laws, regulations, and standards.
Excellent written and verbal communication skills; presentation skills with ability to create and deliver training, informational, and other types of programs. Ability to effectively communicate with individuals at all levels of the organization, as well as external parties. Excellent negotiation and problem-solving skills.
Excellent computer skills, specifically with Microsoft Word, Excel, PowerPoint, and Outlook. Knowledge of Compliance 360 and SharePoint preferred. Ability to learn, understand, and apply new technologies.
Analytical skills, including research skills, ability to interpret data, regulations and laws, ability to conceptualize, and ability to analyze and disseminate information in a readily understandable manner.
Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions.
Ability to plan proactively and interpret complex processes and programs. Excellent follow-up skills to keep projects and tasks on track.
Energetic and forward thinking with high ethical standards and a professional image.
Collaborative and team-oriented; exhibits leadership behavior; serves as a role-model; makes self available to staff; provides regular performance feedback; develops team skills; and encourages individual growth.
Ability to meet stringent deadlines, multi-task, perform a high volume of activities, prioritize work, delegate clearly and effectively, and respond to changing demands.


In addition to competitive salaries, challenging work assignments, and developmental opportunities, Lumeris offers employees a comprehensive benefits package to include medical, dental, vision, life insurance, short-term and long-term disability, paid time off (PTO), matching 401K, and tuition assistance.

For more information on Lumeris careers, please check out our web site:

Lumeris is an EEO/AA employer M/F/V/D.

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Company Description:
Lumeris offers accountable care solutions that enable health care organizations to thrive in value-based care. Our operations, technology and consulting services help health systems, payers and providers manage quality, cost and utilization as part of any value-based contract. Through incentives, tools and information, we empower physicians and administrators to make better-informed, value-based decisions. With our near-decade of experience, unique approach and proven results, we support health care organizations in their transition from fee for service to full risk.

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