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Job Description

Job Title: Compliance Specialist - Medicare Compliance
Job ID: 845222165
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: Medicare Compliance
Location: 600 Grant St, Pittsburgh PA 15219


UPMC Health Plan's Medicare Compliance department is seeking a Compliance Specialist! 

The Compliance Specialist- Insurance is responsible for the monitoring and reviewing of standards and reporting requirements that are an essential component of this position. This individual must have the ability to perform the oversight planning for and implementation of managing all tasks required to meet business needs within the targeted deadlines. Will work with various Health Plan staff to manage the day-to-day activities necessary to meet the myriad requirements of the contract with the Pennsylvania Department of Human Services (DHS) while exceeding their service expectations. 

Must have Medicare Advantage experience and be knowledgeable of the Medicare Communications and Marketing Guidelines.

  • Develop and/or design reports for senior administration as requested by management staff.
  • Establish continuous readiness preparedness for compliance processes.
  • Work collaboratively with management to achieve staff integrated efficiencies. Implement process and/or product improvements on a day-to-day basis, as assigned.
  • Perform analysis of client business problems, participates in identifying solutions, and ensures that the appropriate resolution occurs.
  • Reports on a weekly basis status of all assignments, pertinent information obtained during report week and provides projections for upcoming week to the Senior Director and Manager.
  • Work closely with Legal Department to promote legal compliance of program reporting.
  • Review policies against contractual requirements and participate in the policy committee when applicable.
  • Coordinate with Internal Audit, and Quality Review t to coordinate, monitor, track and trend audits.
  • Research laws, regulations, contractual requirements industry custom, best practices and company preference.
  • Coordinate with the Network Vendor liaison to monitor vendor performance standards.
  • Identifies timelines for reporting requirements and notifies appropriate staff.
  • Assists with the oversight of compliance programs to satisfy contractual requirements and not to place UPMC for You, UPMC for Best Health or UPMC Health Plan in violation of any federal, state regulations, or accreditation standards.
  • Assist in developing regulatory documentation requirements, establishes monitoring tasks and resolves issues.
  • Implement tactical directives emanating from the strategic business plan.
  • Serve as the primary point of contact for programs by serving as the communication liaison with UPMC Health Plan Communication Department, various Health Plan departments and the Department of Human Services. Monitor all member and provider communications and documents.
  • Review DHS and other various web-sites and communicate new and often complex Government rules and regulations relating to compliance requirements.


  • Bachelor's Degree required. 
  • Medicare Advantage experience and knowledge of the Medicare Communications and Marketing Guidelines.
  • Two years of demonstrated experience/knowledge of regulatory compliance or program management preferred. 
  • Excellent organizational capabilities with ability to work effectively as a team player.
  • Program management or supervisory experience in a health care setting preferred. 
  • Strong, problem solving, organizational, and communication skills (oral and written) are required. 
  • Requires excellent project management skills along with effective planning and organizational skills. 
  • Ability to handle multiple priorities/projects in a fast-paced professional environment. 
  • Excellent computer skills required, including Access, Excel, and other software packages. 
  • Demonstrated performance in meeting time-sensitive deadlines with minimal supervision. 
  • Must haves strong analytical and organizational skills as well as problem solving capabilities to ensure that a systematic and thorough monitoring and reporting process is implemented

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

Salary Range: $27.98 to $47.14 / hour

Union Position: No

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