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Job Summary
The Medicare Compliance Officer (MCO) is responsible for the development, implementation and oversight of Priority Health's Medicare compliance program. The MCO will report to the Priority Health VP, Compliance & Privacy Officer with a dotted-line to the Priority Health VP, Medicare. The MCO provides advice and counsel to Priority Health and Corewell Health leaders and departments on compliance matters related to Priority Health's Medicare plans. The MCO serves as the point of contact for Priority Health's CMS regional account manager and serves as the organization's subject matter expert regarding CMS program requirements.
Essential Functions
- Responsible for the development, management, implementation and oversight of the Medicare compliance program. Responsible for the overall direction, performance and supervision of the Medicare compliance teams. Assumes accountability for the team's deliverables, ensuring the achievement of team goals and objectives in addition to individual goals and objectives.
- Assists in and as needed, directs complex compliance investigations and works with operational leaders and assigned Compliance team members to determine the appropriate handling of such issues. May work with external regulatory agencies and legal counsel to resolve compliance issues. Serves as the point of contact for Priority Health's CMS regional account manager.
- Responsible for monitoring developments related to laws and regulations impacting the Medicare Advantage and Prescription Drug Plan, as well as industry trends in Medicare compliance programs. Assists in communicating these developments and responsible for leading the development/modification of policies and procedures to accommodate any legal/regulatory changes and updates. Serves as Corewell Health's subject matter expert regarding CMS program requirements, manuals, published guidance, and rules specific to Medicare managed care.
- Leads compliance initiatives and communication of ongoing compliance efforts, risk identification, audit results, and mitigation efforts to further awareness and effectiveness of the Medicare compliance program. Performs ongoing Medicare compliance risk assessments as a part of the overall enterprise risk management program. Develops and implements the Medicare compliance work plan.
- Presents to various compliance committees, executive leadership meetings, and other meetings as requested on compliance initiatives, audit results and corrective action plans, including the Priority Health Board of Directors. Serves as a member of Priority Health's Compliance Committee, and chair of the Medicare Compliance Subcommittee, as well as leads and participates in associated Medicare compliance subcommittees and internal meetings.
- Collaborates with operational leaders and teams at Priority Health and Corewell Health to change and improve business processes to support, and mitigate risks to, the organization and patient/member rights. Collaborates closely with other key internal stakeholders, including medical, pharmacy, risk adjustment, quality, legal, internal audit, and finance departments, leaders and team members.
- Responsible for coordination, planning and participation in any CMS operational, financial or other audits.
- Mentors, coaches and develops direct reports, and acts as a role model and resource. Holds staff accountable for high performance against job descriptions, policies & procedures, controls and processes, as well as organizational standards and policies. Completes performance reviews, recommends and initiates personnel actions such as interviewing, hiring, performance correction and terminations.
Qualifications
Required
- Bachelor's Degree in law, business, health care operations/management, information technology/information security, nursing or other clinical area
- 5 years of relevant experience in health care compliance and/or clinical or operational leadership experience.
Preferred
- 3 years of relevant experience in managed care setting
- 3 years of relevant experience in Medicare managed care compliance
- Health plan and government programsexperience
- People management experience
- CRT-Healthcare Compliance, Certified (CHC) - HCCA Health Care Compliance Association
Physical Demands
- Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
- Waist to Waist > 5 lbs: Seldom up to 10 lbs
- Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
- Waist to Overhead > 5 lbs: Seldom up to 10 lbs
- Bilateral Carry > 5 lbs: Seldom up to 10 lbs
- Unilateral Carry > 5 lbs: Seldom up to 10 lbs
- Pushing Force > 5 lbs: Seldom up to 10 lbs
- Pulling Force > 5 lbs: Seldom up to 10 lbs
- Sitting: Frequently
- Standing: Occasionally
- Walking: Occasionally
- Forward Bend - Standing: Seldom
- Forward Bend - Sitting: Occasionally
- Trunk Rotation - Standing: Seldom
- Trunk Rotation - Sitting: Occasionally
- Reach - Above Shoulder: Seldom
- Reach - at Shoulder or Below: Seldom
- Handling: Occasionally
- Forceful Grip > 5 lbs: Seldom
- Forceful Pinch > 2 lbs: Seldom
- Finger/Hand Dexterity: Frequently
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here. On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status
Primary Location SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids
Department Name System Compliance - Corporate
Employment Type Full time
Shift Day (United States of America)
Weekly Scheduled Hours 40
Hours of Work 8 a.m. to 5 p.m.
Days Worked Monday to Friday
Weekend Frequency N/A
CURRENT COREWELL HEALTH TEAM MEMBERS - Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447.
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Corewell Health
Mar 02, 2026