Government Programs Compliance Lead

Job Description Summary:

The Compliance Lead for Government Programs serves as a senior subject matter expert supporting the Medicare Compliance Officer in executing and continuously enhancing the compliance program in alignment with CMS requirements and the seven elements of an effective compliance program. This role drives the operationalization of key compliance functions including policies and procedures, training, monitoring and auditing, and issue investigation and remediation while proactively identifying and mitigating compliance risks across Medicare Advantage (Part C) and Part D operations. Acting as a primary liaison to operational teams, the position translates complex regulatory requirements into practical, embedded business processes, ensures compliance integration into day-to-day activities, and provides expert guidance across core functional areas such as claims, pharmacy, utilization management, and appeals, with a strong emphasis on enterprise risk assessment and regulatory alignment.

Responsibilities include but are not limited to:

• Support the Medicare Compliance Officer in the execution and continuous improvement of the compliance program, ensuring alignment with CMS requirements and the 7 elements of an effective compliance program, with a focus on proactive risk identification and mitigation. Operationalize compliance program elements, including: Policies and procedures development and implementation, Training and awareness initiatives, Monitoring, auditing, and data-driven oversight, Issue identification, investigation, and corrective action planning
• Provide deep subject matter expertise in Medicare Part C and/or Part D operations, with the ability to assess compliance risks within core functional areas (e.g., claims processing, utilization management, pharmacy operations, coverage determinations, grievances/appeals)
• Serve as the primary compliance liaison to Association Medicare operational teams, ensuring alignment with regulatory requirements across Medicare Advantage (Part C) and Part D programs, including oversight of compliance integration within day-to-day operations. Experience supporting EGWP plans is strongly preferred
• Partner with operational and business teams to translate Medicare regulatory requirements into actionable, operational processes, ensuring compliance is embedded into workflows across key operational functions
• Support ongoing risk assessment activities, incorporating insights from audits, FDR monitoring, and committee reporting to continuously enhance compliance program effectiveness and proactively address emerging regulatory risks

The posting range for this position is:

113,572.92 - 153,590.12

Required Education, Certifications and Experience:

Education:

• Required BS

Experience:

• Required 7+ Years

Knowledge Skills and Abilities:

• Deep knowledge of CMS Medicare regulations and guidance (including 42 CFR Parts 422/423, CMS manuals, HPMS guidance, and audit protocols)
• Understanding of the 7 Elements of an Effective Compliance Program and ability to operationalize them across Medicare Advantage and Part D programs
• Knowledge of Medicare Part D and/or MA-PD program requirements including enrollment, claims, formulary, pharmacy operations, and member protections
• Knowledge of Fraud, Waste, and Abuse (FWA) requirements and detection methodologies including exclusion screening, investigations, and reporting obligations
• Ability to conduct regulatory gap analyses and translate requirements into actionable controls across operational functions (e.g., claims, UM/CM, network, enrollment)
• Strong auditing and monitoring capabilities including development of work plans, identification of compliance risks, and use of data-driven oversight
• Ability to design, implement, and evaluate corrective action plans (CAPs) ensuring timely remediation and sustainable compliance outcomes Knowledge of CMS audit processes and audit-readiness expectations including document production, universes, and issue remediation lifecycle
• Ability to interpret and apply regulatory requirements to complex business scenarios and provide practical, risk-based compliance guidance to operational stakeholders Strong governance and reporting skills including experience supporting compliance committees, senior leadership reporting, and Board-level oversight
• Effective communication skills with the ability to translate regulatory requirements into clear guidance, training, and business-friendly language
• Knowledge of privacy, data governance, and handling of sensitive information particularly as it relates to Medicare data and compliance investigations
• Ability to manage relationships with internal stakeholders and FDRs to ensure compliance expectations are understood, implemented, and monitored
• Strong analytical and problem-solving skills with the ability to identify root causes of compliance issues and recommend sustainable solutions
• High level of professional integrity and judgment including the ability to identify, escalate, and address potential compliance risks or noncompliance

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