VP Ethics & Compliance Officer

How Is This Role Important to Our Work?

The Vice President (VP) Ethics & Compliance Officer is responsible for leading and developing all facets of the company's ethics and compliance programs, ensuring adherence to all applicable laws, regulatory and compliance requirements. The role oversees, monitors, and reports on compliance activities across the organization including organizing and directing strategies and processes that assure that the organization meets or exceeds state, federal and local government regulatory requirements. This position also has accountability for the Special Investigations Unit (SIU) which monitors for claims fraud, waste, and abuse, and Performance Measurement and Reporting (PMR) which conducts audits of key business functions and performance guarantee requirements. The position is accountable for the interaction between Blue Cross and external regulatory agencies and the Board on issues of compliance, regulation, and ethics, and works directly with all functional business unit executives and external regulatory agencies to assure that business processes are compliant. The VP Ethics & Compliance Officer sets the strategic direction for the areas listed above and will influence and collaborate with internal and external stakeholders. This position reports to the Audit Committee of the Board of Directors and administratively to the Chief Legal Officer.

Job Responsibilities:

• Provide strategy and overall direction for the establishment and maintenance of corporate ethics, compliance, and special investigations programs and policies that meet the needs of the company, including but not limited to compliance with state, federal and government health care program requirements.

• Lead and participate in the Corporate Ethics & Compliance Committee.

• Maintain an effective ethics and compliance program with standards, procedures, and internal controls designed to detect violations of law and other misconduct and promote ethical conduct and a commitment to compliance with the law. Ensure that standards, procedures, and internal controls are adopted, published, and explained to associates and agents.

• Accountable for interactions between BlueCross, external regulatory agencies, and the Board.

• Develop and monitor implementation of compliance and ethics programs with applicable policies and procedures while coordinating with other departments to ensure effective implementation; identify, assess, and manage legal and regulatory risk, and ensure that vulnerable risk areas are appropriately addressed.

• Provide compliance training and awareness programs to associates and educate them on compliance standards and best practices. Educate enterprise-wide workforce by keeping associates informed of legal changes and updates to compliance guidelines.

• Ensure effective systems are in place for associates and other agents to raise concerns and obtain advice regarding ethics, compliance, and report misconduct without fear of retaliation.

• Lead a team to perform regular compliance monitoring and auditing; Deliver reporting on compliance matters including but not limited to training, instances of actual or potential noncompliance, and oversight and auditing activities to the Chief Legal Officer, Chief Executive Officer, and the Audit Committee of the Board.

• Remain updated on relevant laws and regulations, communicate with stakeholders about regulatory initiatives, and assist with implementation of regulatory changes.

• Develop and implement strategies to lead and direct the Special Investigation Unit (SIU), ensuring that investigators are trained and certified, and industry tools and internal collaboration are maximized to prevent, detect, investigate, and recover from fraud, waste, and abuse. Ensure investigations are conducted with integrity and leading practices are followed.

• Develop and maintain policies and procedures for the SIU, and report on the effectiveness of the SIU to the Chief Legal Officer and other stakeholders.

• Develop and implement strategies to lead and direct Performance Measurement and Reporting (PMR), to audit delivery of the company's performance guarantee requirements, conduct risk mitigation claim audits, ensure results are reported for all required measures, ensure coordination of all regulatory audits, collaborate discovery efforts with Legal, and support the internal audit department in organizational reporting.

• Ensure that applicable contractual and regulatory requirements are achieved.

• Collaborate with law enforcement and regulatory agencies.

• Consult with management, and function as a contact person and liaison between department heads and senior management. Implement and maintain effective escalation protocols.

• Address concerns, escalate appropriately, and find solutions to regulatory risks or misconduct.

• Establish and oversee an effective, comprehensive conflict of interest program to prevent, identify, and address potential conflicts within the organization.

• Foster a culture of compliance and ethical conduct throughout the organization.

Preferred Qualifications:

• Juris Doctor (JD) or equivalent legal background strongly preferred

• Master of Business Administration (MBA), or Master's degree in Health Administration

• 15+ years of Ethics and Compliance management experience within health insurance industry

• 10+ years of managerial and people leadership experience

• Compliance certifications

Required Skills and Experiences:

• Accepting this VP level position at BCBSMN requires signing an Employee Confidentiality, Intellectual Property Assignment and Restrictive Covenants Agreement as a condition of employment.

• 10+ years of related professional experience in healthcare, compliance, legal or regulatory affairs, with 5+ years of management experience. All relevant experience including work, education, transferable skills, and military experience will be considered.

• Strong knowledge of healthcare laws and regulations, including Fraud, Waste, and Abuse (FWA) requirements.

• Proven leadership experience in managing compliance programs and conducting investigations.

• Deep understanding of risk management practices and compliance standards and protocols.

• Demonstrated ability to develop collaborative and high-level relationships with key internal and external representatives and work collaboratively across departments and with external partners.

• Demonstrated organizational relationship management skills, diplomacy, and the ability to navigate complex political situations effectively.

• Expert verbal and written communication skills; ability to successfully present complex and sensitive issues to executives, the Board, and other audiences. Able to tailor message to the audience and keep people up to date with information.

• Demonstrated superior analytical, decision-making, problem solving, and negotiation skills and the ability to drive strategies and implement and execute programs. Able to anticipate long-term challenges and trends and able to understand the implications of decisions.

• Able to translate ideas and concepts into practical applications; sees how their work relates to the work of other teams and the organization as a whole; learns/knows which people in the organization need to be informed, what they need to know, and when to tell them.

• Proactively manage execution by organizing and coordinating resources, time, and people to achieve key goals and objectives; prioritize goals and use resources appropriately while considering both strategy and efficiency.

• Exceptional talent management and team leadership skills. Demonstrated ability to provide clear, motivating, and constructive feedback, provide challenging assignments, coaching, and is a demonstrated champion of a talented and diverse workforce.

• Must possess the highest ethical standards and share the organization's commitment to its values.