Job Description
Job Description
POSITION SUMMARY
The Compliance Specialist supports the organization’s Medicare Advantage program and SMAC contract by ensuring compliance with all applicable federal and state regulations, including CMS (Centers for Medicare & Medicaid Services) requirements. This position reports to the Director of Compliance and is responsible for monitoring regulatory updates, conducting compliance reviews, analyzing policies and procedures, supporting internal and external audits, and assisting in the development and implementation of corrective action plans. The Compliance Specialist collaborates with internal departments and external partners to promote adherence to contractual and regulatory obligations, minimize compliance risks, and support a culture of compliance across the organization. Position is onsite Monday-Friday.
ESSENTIAL DUTIES AND RESPONSIBILITIES
• Monitor federal and state regulatory requirements applicable to the Medicare Advantage program and SMAC contract, including guidance issued by CMS and other regulatory bodies. • Conduct regular compliance reviews, audits, and monitoring activities to ensure adherence to contractual, regulatory, and internal policy requirements.
• Research, analyze, and interpret new or updated laws, regulations, and CMS guidance; communicate impacts and recommended actions to relevant departments.
• Assist with the development, implementation, and maintenance of policies and procedures to ensure ongoing compliance with applicable regulations and contractual obligations.
• Support the preparation and submission of regulatory filings, reports, and attestations through HPMS and other required platforms. • Review Annual Enrollment Period (AEP) materials, including Evidence of Coverage (EOC), Annual Notice of Change (ANOC), Summary of Benefits (SB), and other required member communications to ensure accuracy, regulatory compliance, and timely submission to CMS.
• Oversee ongoing review of member-facing materials and communications to ensure they meet CMS requirements and organizational standards; coordinate submission and approvals through HPMS or other CMS portals as needed.
• Monitor and manage CTM (Complaint Tracking Module) cases to ensure timely and accurate resolution in compliance with CMS requirements; track and report trends to identify potential areas for improvement. • Participate in the receipt, tracking, investigation, and resolution of compliance-related issues, including grievances, complaints, CTM cases, and regulatory inquiries.
• Assist with internal and external audits, including gathering documentation, responding to requests for information, and coordinating with operational departments.
• Prepare for and support Compliance Committee meetings, including developing agendas, compiling and presenting compliance data and reports (such as CTM and HPMS updates), drafting meeting minutes, tracking action items, and coordinating follow-up activities with responsible departments. Reports To: FSLA Status: CCO Exempt Created on: Last date revised: Division/Department: 9/23/2024 9/24/2024 Compliance Job Title Compliance Specialist
• Develop and deliver training and educational resources to internal stakeholders on compliance requirements, policies, and processes, including HPMS memos, CTM handling, and member communications requirements. • Maintain organized and up-to-date compliance documentation, logs, CTM tracking, HPMS submissions, and other required compliance tracking tools.
• Collaborate cross-functionally with other departments (e.g., Operations, Marketing, Quality, Member Services) to ensure compliance requirements are incorporated into business processes and member materials. • Escalate potential compliance risks or issues to the Director of Compliance and recommend corrective actions when needed.
• Perform other related duties as assigned to support the Compliance Department and ensure regulatory readiness.
QUALIFICATIONS AND EDUCATION
• Bachelor’s or master’s degree in healthcare administration. • Minimum of 2–4 years of experience in healthcare compliance, preferably with Medicare Advantage or Medicaid programs
• Knowledge of CMS regulations, Medicare Advantage requirements, SMAC contracts, and compliance best practices.
• Experience working with CTM (Complaint Tracking Module), HPMS (Health Plan Management System), and other compliance monitoring tools preferred.
• Strong analytical, research, and problem-solving skills.
• Excellent verbal and written communication skills, including ability to prepare reports and deliver presentations.
• Detail-oriented with strong organizational and time-management skills.
• Ability to collaborate effectively across multiple departments and manage multiple projects simultaneously. KNOWLEDGE AND SKILLS
• In-depth understanding of healthcare regulations and compliance standards related to Medicare Advantage and Medicaid programs.
• Familiarity with CMS reporting requirements, including HPMS and CTM processes.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook). • Ability to analyze complex regulatory information and translate it into actionable business guidance.
• Strong interpersonal skills to build relationships with internal teams and external regulatory bodies.
• Ability to maintain confidentiality and handle sensitive information with discretion.
• Project management skills to support audits, policy development, and committee activities
WORKING CONDITIONS
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• The noise level in the work environment is usually moderate.
• Fast-paced office environment.
• Highly regulated environment.
• Interacts with patients, family members, staff, visitors, government agencies, etc, under a variety conditions and circumstances.
This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.
The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or listen. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.