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UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

If you are not yet vaccinated, we urge you to get a vaccine now. You can schedule your COVID-19 vaccination through UPMC or visit a non-UPMC provider or UPMC Urgent Care location.

Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

For more information about UPMC’s response to COVID-19, please visit UPMC.com/coronavirus.

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Sr. Director, Commercial Compliance

Description

The Sr. Director, Commercial Compliance reports to the Senior Vice President, Chief Risk, Compliance & Ethics Officer and strategically and operationally leads the development, implementation and management of a robust and effective Commercial Compliance Program for UPMC's large and growing Insurance Services Division. This position strategically ensures compliance with all relevant and applicable laws, regulations, government contracts, standards, and requirements in a manner that continually supports the business and operational areas. The position additionally oversees our Federal Employee Health Benefits (FEHB) Program, ancillary/third-party administrator (TPA), Exchange, Children's Health Insurance Program (CHIP), and Workpartners (workers' compensation, leave management, wellness, and data analytics) compliance programs and functions.

Responsibilities:

  • Oversees and ensures compliance with all relevant and applicable laws, regulations, government contracts, requirements, standards and practices for all relevant stakeholders, both internal and external to the organization, for the Commercial, ancillary, FEHB, Exchange, CHIP, TPA, workers' comp, leave management, wellness and other Workpartners lines of business (hereafter collectively referred to as "Commercial Compliance").
  • Develops, assesses, and adapts clear and effective Commercial Compliance policies, procedures, training, communications and awareness materials, campaigns, controls, and initiatives to ensure clear and consistent preventive measures, understanding, and practices throughout internal and external operations.
  • Develops, assesses, and adapts clear and effective Commercial Compliance monitoring, testing, reporting, auditing, and sampling protocols, controls, and channels, in collaboration with the Quality Assurance Department, to ensure the proper and timely detection of relevant issues.
  • Develops, assesses and adapts clear and effective remediation and corrective action initiatives, protocols, and controls to ensure proper and timely compliance.
  • Keeps abreast of changing industry requirements and regulations, including all relevant laws, rules, agency guidance, government contracts, industry standards, company practices and initiatives. Provides clear and effective reports to the relevant business, functional and operational areas, as well as other internal/external stakeholders, regarding new or prospective laws, regulations, contractual requirements, industry standards and best practices.
  • Oversees and directs ongoing Commercial Compliance training to UPMC Insurance Services Division staff and applicable parties.
  • Oversees and directs regular gap analyses, risk assessments, work plans and program effectiveness.
  • Assessments for the Commercial Compliance Program.
  • Ensures strategic and operational partnership and collaboration with the business and operational areas, as well as with sibling Governance, Risk & Compliance (GRC) teams to leverage cross-departmental synergy and efficiencies.
  • Represents UPMC Insurance Services Division with all relevant regulatory agencies, employer groups (i.e., customers) and entities regarding Commercial Compliance reviews, investigations or requests for information.
  • Develops and reports clear and relevant Commercial Compliance Program metrics and dashboards to measure Program effectiveness and to proactively identify relevant trends and patterns.
  • Develops and delivers clear, effective and timely reports and updates for senior management and/or the Board regarding the Commercial Compliance Program effectiveness, initiatives and issues, including all relevant metrics, dashboards and information.

Qualifications

  • Bachelor's degree required. Relevant graduate degree (e.g., Juris Doctor or Master's degree in a related field) preferred.
  • Minimum of 8 years of commercial health insurance (payer) legal and/or compliance-related experience required.
  • Prior in-house legal or compliance experience strongly preferred.
  • Pennsylvania-specific commercial compliance experience preferred, but not required.
  • Workers' compensation and/or ancillary/third-party administrator compliance experience preferred, but not required.
  • Minimum of 5 years of work experience in a managerial/leadership role.
  • Successful experience in designing and building highly effective compliance programs from scratch and/or significantly enhancing such programs strongly preferred.
  • Strong industry subject matter expertise and knowledge of all relevant laws, regulations, contractual requirements, industry standards and best practices required.
  • Strong project management skills and experience required, particularly as it relates to managing and leading across large and matrixed organizations.
  • Must have strong analytical and organizational skills as well as problem-solving capabilities to ensure that business plans and strategies do not subject the organization to legal, regulatory, or contractual violations and/or undue risk or exposure.
  • Strong partnership-, relationship-, consensus- and coalition-building skills required.
  • Strong emotional intelligence and self-awareness required.
  • Strong executive polish and presence required.
  • The role requires a leader who strikes the optimal balance between strategically navigating the compliance requirements and business needs in a manner that is nuanced and mutually reinforcing.
  • Strong strategic, business, operational and leadership mindset and skills required.
  • Highly consultative and partnership-oriented in approach.


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