Director, Medicare Compliance

Dover, New Hampshire
Not Specified
Nov 19, 2020
Jan 18, 2021
Job Type
Not Specified
Career Level
Not Specified

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Director, Medicare Compliance leads, plans, organizes, and directs all Medicare related work for Workers Compensation Claims countrywide. Responsible for ensuring that adequate levels of expertise is maintained for GRS WC Regions and specific areas of Liability/NoFault/Med Pay within GRS. Uphold full compliance with Medicare Reporting, Conditional Pay and MSA handling for GRS. Build and strengthen relationships and actively partner with all stakeholders. Proactively assess compliance and respond to regulatory reform. Maintain Medicare professional designations to facilitate Liberty Mutuals commitment externally with our customers and CMS. Build an environment that supports team members development & career advancement opportunities.


  • Ensure the Medicare units comply with Quality Standards and demonstrate CI Claims Service Principles in their work product. Lead team to mitigate exposure by effectively managing medical costs as well as mitigating Conditional Pay exposures. Participate with Networks and PBM to create long term solutions to identify and mitigate clinical opportunities earlier in the life of a claim.
  • Partners with Vendor Mgt as the expert to facilitate and oversee strategic vendor partnerships including MSA, Medicare reporting, Rated Ages and Reversionary Interest/Professional Administration
  • Maintain focus on effective resolution until disposition of referred cases, employing all tools, resources and techniques available as needed. Countrywide oversight of the Medicare Unit and outcome improvement through resolution, MSA expertise, MSA Mitigation, PBM, Conditional Pay, Section 111 and Medicare compliance.
  • Monitors Medicare & Medicaid legislative updates, provides insight into regulatory reform efforts and collaborates with Federal Affairs Dept., HO Legal, Compliance Dept. and Field Claims. Engage with WC Examining, Training and Field Claims operations as appropriate to facilitate training, build field expertise. Encourage Medicare Unit to collaborate with the field on any CMS updates, engagement in huddles or new tools. Updates to Inkling material.
  • Build and strengthen relationships and actively partner with internal and external stakeholders including consistent compliance with Special Service Instructions at the desk, team, and office level. Engage Sales/Service to clarify SSIs and work pro-actively with requests for non-approved vendors.
  • Build an environment that supports Team Members development & career advancement opportunities. Foster and develop a culture of responsiveness, accountability, and consistent performance.
  • Leverage Best Practices, Local Leadership & the LMS process to drive sustained improvement in key areas as identified in the Employee Opinion Survey. Timely & appropriate recognition of staff performance via Shine, All Stars, Best Work, and Chairman/Presidential Awards. Demonstrating a high level of professionalism and teamwork.
  • Maintain accurate staff levels while managing workload and achieve production targets. Identify waste and opportunities to create efficiencies through our LMS root cause problem solving. Achieve & maintain acceptable performance on all Internal Audit measures and State compliance measures including but not limited to form filings, licensing, and market conduct reviews.
  • Lead a team of technical experts (Examiners, CCMU Nurses, and Life Pension Analysts) to include coaching, mentoring, training, performance reviews, and leveraging own technical expertise in achieving department objectives. Achieve work through others direct reports and business partners. Assist VP & Manager of Technical Solutions when/where required.

Demonstrated ability to lead and manage a highly experienced technical team of individuals in the oversight of significant exposure, catastrophic, complex and unique claims. Ability to work well and in conjunction with large national account customers, understand special service instructions and build partnerships with Account/Service Managers, Underwriters, Distribution and Agents/Brokers. Extensive knowledge of Claims Department procedures and operations a plus. A Bachelors degree or equivalent, 10+ years of related claims experience, and prior management experience required.