Director Medicare Compliance

Job Summary:

The Medicare Compliance Officer (MCO) is responsible for developing, implementing, and overseeing the compliance program for Medicare Advantage (Part C) and Medicare Part D activities for Mercy Care Plan, managed by Aetna, a CVS Company. This role ensures adherence to all applicable federal and state regulations and CMS requirements, safeguarding the integrity and compliance of Plan operations.

Reporting Structure:

This position will maintain day-to-day operational alignment with the Mercy Care Medicare team while holding direct reporting accountability to the Chief Executive Officer (CEO) and the Audit and Compliance Committee of the Mercy Care Plan Board of Directors.

• Provide formal reports to the Board of Directors, CEO, and Compliance Committee at least quarterly, and more frequently as needed, detailing the status of Mercy Care Plan’s Medicare Compliance Program implementation, identification and resolution of compliance issues, and oversight and audit activities.
• Oversee the development and administration of the Board of Directors’ annual Code of Conduct and compliance training program, including program design, content creation, distribution, tracking, and ongoing maintenance to ensure full compliance with regulatory and organizational standards.
• Develop and implement programs and mechanisms that promote a culture of integrity by encouraging managers and employees to report suspected fraud, waste, abuse, or other misconduct, ensuring confidentiality and protection against retaliation.
• Respond promptly to reports of potential Medicare fraud, waste, or abuse, (FWA) including coordinating internal investigations and developing appropriate corrective or disciplinary actions when necessary. Maintain the FWA reporting mechanism and collaborate closely with the Internal Audit Department and the Special Investigations Unit (SIU), as applicable.
• Exercise flexibility in designing and managing internal investigations (e.g., addressing suspected violations or reported issues) and implementing resulting corrective measures, such as policy enhancements and disciplinary actions to ensure compliance and mitigate risk.
• Coordinate with the Plan’s Human Resources department (or equivalent) to ensure thorough screening of the DHHS OIG and GSA exclusion lists for all employees, officers, directors, managers, and contracted entities, including first-tier, downstream, and related entities, confirming none are listed on these exclusions.

Required

• Bachelors Other or an equivalent combination of directly related workexperience and/or education and
• Five (5) years of experience that demonstrates solid Medicare compliance program development, operation and administration responsibilities

Preferred

• Registered Nurse: AZ

Knowledge Skills and Training:

• Strong Business acumen and healthcare industry

Hello humankindness

Located conveniently in the heart of Phoenix, Arizona,St. Joseph's Hospital and Medical Center is a 571-bed, not-for-profit hospital that provides a wide range of health, social and support services. Founded in 1895 by the Sisters of Mercy, St. Joseph's was the first hospital in the Phoenix area. More than 125 years later, St. Joseph's remains dedicated to its mission of caring for the poor and underserved. We are extremely proud to be a nationally recognized center for quality quaternary care, medical education and research. St. Joseph's includes the internationally renowned Barrow Neurological Institute, Norton Thoracic Institute, Cancer Center at St. Joseph's, Ivy Brain Tumor Center, and St. Joseph's Level I Trauma Center (which is verified by the American College of Surgeons). The hospital is also a respected center for high-risk obstetrics, neuro-rehabilitation, orthopedics, and other medical services. St. Joseph’s is considered a sought-after destination hospital for treating the most complex cases from throughout the world. Every day, approximately 20 percent of the hospital’s patients have traveled from outside of Arizona and the United States to seek treatment at St. Joseph’s. U.S News & World Report routinely ranks St. Joseph's among the top hospitals in the United States for neurology and neurosurgery. In addition, St. Joseph's boasts the Creighton University School of Medicine at St. Joseph's, and a strategic alliance with Phoenix Children's Hospital. St. Joseph's is consistently named an outstanding place to work and one of Arizona's healthiest employers. Come grow your career with one of Arizona's Most Admired Companies. Look for us on Facebookand follow us on Twitter. For the health of our community ... we are proud to be a tobacco-free campus.