Job Description

Job Title: Senior Director, Commercial Compliance
Job ID: 180001CA
Status: Full-Time
Regular/Temporary: Management
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Compliance & Ethics
Location: 600 Grant St, Pittsburgh PA 15219

Description

Are you a proven leader with a minimum of eight years of commercial health insurance (payer) legal and/or compliance experience? Are you a driven individual looking to not only tactically ensure compliance but also be a part of program development? If so, we may have an opportunity for you?


UPMC is actively seeking a full time Senior Director, Commercial Compliance to support UPMC Health Plan! This will be a Monday through Friday daylight role located in Pittsburgh, PA. 


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, contractual agreements, standards and requirements in a manner that continually supports the business and operational areas.  The position additionally oversees our workers’ compensation and ancillary/third-party administrator (TPA) compliance programs and functions.


Responsibilities

  • Ensures compliance with all relevant and applicable laws, regulations, contractual requirements, standards and practices for all relevant stakeholders, both internal and external to the organization.

  • 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 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, contractual agreements, 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 annual and ongoing Commercial Compliance training to UPMC Insurance Services Division staff and applicable parties.

  • Oversees and directs regular gap analyses, risk assessments 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.

  • Performs other duties as assigned.

  • Effectively lives, models, communicates and supports the values of UPMC and UPMC Health Plan.

  • Performs in accordance with UPMC System-wide competencies and behaviors.

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 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 acumen and understanding of healthcare, health insurance and managed health care industries and organizations required.

  • Excellent oral, listening and written communication skills.

  • 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.

  • Strong and reliable judgment and discretion required.  Strong ability to independently and self-sufficiently identify, navigate and successfully resolve various compliance, risk management and regulatory issues.

  • Strong ethical compass and integrity capital required.

Salary Range: $0 to $0

Union Position: NA

At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!

QUALITY & SAFETY
DIGNITY & RESPECT
CARING & LISTENING
RESPONSIBILITY & INTEGRITY
EXCELLENCE & INNOVATION

UPMC provides a total rewards package that can help you achieve the goals you have for your career and your personal life. Whether you want to learn a new skill through a training course, reach personal health and wellness targets, become more involved in your community, or follow a career path that provides you with the right experience to be successful, UPMC can help you get to where you want to be.



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