Under the direction of the Director of Senior Markets Performance Improvement, Sales Operations and Analysis the Program Manager, Program Integrity, will act as the business liaison to Medicare Compliance, the Mandates Control Group, and Government Affairs. This role will be key and critical in validating that regulatory and compliance impacts to Senior Markets are identified and plans to meet these are crafted and supplied to implementation teams in a timely and integrated fashion. This role will work with cross-functional teams that support Senior Markets to ensure the business is prepared and ready to meet all CMS rules, as well as federal and state guidelines. The role will collaborate with our internal compliance and mandates partners to escalate if compliance measures are not being met, assess financial impact, and assist (as needed) in mobilizing the appropriate business resources to correct deficiencies and inefficiencies. The role will maintain a high level of exposure and awareness to changes within the regulatory environment to deliver exceptional operational compliance and effectiveness.
- Responsible for providing support to develop, monitor, improve operational controls to be audit ready from end to end for our Senior business.
- Ability to read, interpret and operationalize federal and state regulatory requirements including developing and consulting on various impact assessments to aid stakeholders in decision making. Keeps abreast of changing business needs and helps to identify areas of process redesign to influence initiatives.
- Works with key operational leadership, compliance team and mandates to develop, maintain and provide leadership in the development of new methodology and technology that allows Blue Shield of California continuous regulatory adherence.
- Ensures that leadership is informed and understands the timing, impacts, to apply appropriate business strategies within the overall program.
- Routinely meets with various stakeholders to assess business directions and the strategic direction of the company to partner on meeting corporate goals within the various regulatory parameters.
- Develops long-range and short-term goals, objectives and plans to assure the development, implementation, maintenance, and improvement of compliance/operational effectiveness.
- Serves as positive role model and effective liaison for the organization and its internal and external connections and works collaborative with leadership to foster a culture of audit ready integrity throughout the organization.
- Lead and/or participate in large/complex projects/programs for Senior Markets.
- Exercises independent judgement in developing methods, techniques, and evaluation criteria for obtaining results.
- May influence on business unit or function strategies and objectives as part of a broader management team.
- May act as the business unit liaison to corporate and cross-functional initiatives and projects.
- May be responsible for assembling a project team, assigning, and monitoring work of team members and providing guidance and leadership.
- May perform operational responsibilities.
- Other ad hoc duties pertaining to the job.
Knowledge and Experience
- Typically, requires a college degree or equivalent experience and minimum 7 years of prior relevant experience.
- Masters’ degree strongly preferred.
- Demonstrated understanding of Medicare Advantage and Medicare Supplement managed care health plan customer needs, including expected service experiences required.
- Experience with process improvement and creation of scalable, automated processes; certified with Lean, Six Sigma, or other process improvement methodologies highly preferred.
- Previous project management experience strongly preferred.
- Demonstrated experience with extensive knowledge of products, operational functions, performance standards, marketing and/or service policies and procedures.
- Ability to collaborate and negotiate with and influence team members of all-levels functioning in a matrix environment including managers and executives.
- Demonstrated leadership, project management, program evaluation and reporting skills.
- Proven success with driving high priority and/or highly sensitive projects on time and on budget.
- Experience in managing highly visible, complex, cross-functional programs or projects in a fast-paced environment.
- Demonstrated strengths at thriving in highly ambiguous and evolving environments, as well as high profile, urgent situations.
- Knowledge in developing and implementing company-wide, organizational development or process improvement programs.