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AVP, Medicare Advantage C-SNP Compliance Verda Healthcare Inc - 1.0 Huntington Beach, CA Job Details Full-time $160,000 - $190,000 a year 5 hours ago Benefits Paid holidays Health insurance Dental insurance 401(k) Paid time off Vision insurance Life insurance Qualifications Medicare Health insurance knowledge Cross-functional collaboration Cross-functional team management Cross-functional communication Full Job Description Verda Healthcare, Inc. is a Medicare Advantage Prescriptions Drug Plan (MAPD) organization committed to the idea that healthcare should be easily and equitably accessed by all, currently available in Texas and Arizona. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for an AVP, Medicare Advantage C-SNP Compliance to join our growing company with many internal opportunities. Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare plan is looking for people like you who value excellence, integrity, care and innovation. As an employee, you'll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity. Align your career goals with Verda Healthcare, Inc. and we will support you all the way. Position Overview AVP, Medicare Advantage C-SNP Compliance is responsible for leading and overseeing compliance with CMS Medicare Advantage, Chronic Condition Special Needs Plan (C-SNP), and applicable federal and state regulatory requirements. This position serves as a key compliance authority for the C-SNP program and is accountable for establishing effective controls, monitoring operational performance, identifying regulatory risks, coordinating audits, managing corrective actions, and ensuring that the organization can demonstrate compliance to CMS and other regulators. The Compliance Officer will work closely with Clinical, Operations, Quality, Utilization Management, Network, Pharmacy, Member Services, Enrollment, Marketing, IT, Analytics, delegated entities, and executive leadership to ensure that C-SNP requirements are consistently implemented and documented. This position reports to Chief Compliance Officer/Chief Executive Officer.

Responsibilities:

1. C-SNP Regulatory Compliance Maintain comprehensive knowledge of CMS Medicare Advantage and C-SNP requirements. Monitor regulatory changes, CMS guidance, HPMS communications, audit protocols, and applicable federal and state requirements. Translate regulatory requirements into operational policies, procedures, controls, workflows, and measurable accountability. Ensure C-SNP operations remain aligned with the approved SNP Model of Care (MOC) and applicable CMS requirements. Medicare Advantage C-SNP Compliance Officer Maintain a centralized C-SNP compliance calendar and regulatory obligation inventory. 2. SNP Model of Care Compliance Oversee implementation and ongoing compliance with the organization's approved C-SNP Model of Care.

Monitor required processes involving:

o Health risk assessments o Individualized care plans o Interdisciplinary care teams o Care coordination o Beneficiary access and communication o Transitions of care o Provider engagement o Care management o Quality improvement Establish monitoring mechanisms to identify gaps in MOC implementation. Ensure deficiencies are documented, assigned, corrected, and validated. 3. CMS Audit and Regulatory Readiness Lead organizational readiness for CMS program audits, C-SNP audits, data validation, and other regulatory reviews. Coordinate responses to CMS, state regulators, auditors, and other oversight organizations. Ensure audit evidence is accurate, complete, timely, and traceable to the applicable requirement. Establish audit response ownership across business units. Review audit findings before submission and ensure management understands potential compliance implications. Track corrective actions through completion and validation. 4. Compliance Monitoring and Oversight Develop and maintain an ongoing compliance monitoring program covering areas such as: Enrollment and eligibility C-SNP eligibility and qualifying conditions Member communications Marketing and sales Provider requirements Care management Utilization management Quality and Star Ratings HEDIS Medication management and pharmacy Claims and encounter data Risk adjustment/HCC activities Medicare Advantage C-SNP Compliance Officer Grievances and appeals Access and availability Delegated entity performance Member rights and protections Fraud, Waste and Abuse Privacy and security Cultural and linguistic requirements Prepare regular compliance reports identifying open issues, responsible owners, due dates, risk levels, corrective actions, and escalation requirements. 5. Delegated Entity Compliance Because Medicare Advantage operations may rely heavily on delegated providers and vendors, the Compliance Officer will: Establish compliance requirements for delegated entities. Monitor delegated entities against contractual and regulatory obligations. Review delegated entity audit results, compliance reports, and performance metrics. Ensure appropriate oversight, documentation, and escalation of deficiencies. Coordinate corrective action plans when delegated entities fail to meet requirements. Maintain evidence demonstrating that the Plan is exercising appropriate oversight of delegated functions. 6. Corrective Action and Issue Management Maintain a formal compliance issue and corrective action tracking process. Investigate identified compliance deficiencies and determine appropriate remediation. Assign accountable owners and measurable completion dates. Escalate overdue or high-risk issues to executive leadership and the Compliance Committee. Validate that corrective actions actually resolved the underlying issue rather than merely addressing documentation. Maintain evidence supporting closure of compliance findings. 7. Policies, Procedures and Documentation Develop, review, and maintain compliance policies and procedures. Ensure policies accurately reflect current CMS requirements and operational practices. Identify discrepancies between written policies and actual business processes. Establish appropriate documentation standards to ensure the organization can demonstrate compliance during an audit. 8. Training and Compliance Culture Develop and coordinate compliance training for employees, providers, delegated entities, and applicable contractors. Medicare Advantage C-SNP Compliance Officer Provide targeted training when regulatory changes or audit findings identify knowledge gaps. Promote a culture in which compliance ownership resides with the responsible business unit rather than solely with the Compliance Department. 9. Reporting and Executive Governance Provide regular reporting to executive leadership and applicable governance committees regarding: C-SNP compliance status Regulatory changes Open compliance risks CMS audit readiness MOC compliance Delegated entity performance Corrective action status Material incidents Overdue remediation Emerging regulatory risks Immediately escalate significant compliance concerns that may expose the organization to regulatory action, financial penalties, member harm, contractual consequences, or CMS sanctions. Preferred Qualifications Experience working directly with CMS or CMS audit contractors. Experience with SNP Model of Care implementation and monitoring. Medicare Advantage compliance certification such as CHC, CHPC, CCEP, or equivalent. Medicare Advantage C-SNP Compliance Officer Clinical background such as RN, LPN, social work, or healthcare management. Experience with CMS HPMS and Medicare Advantage regulatory communications. Experience with delegated medical groups, IPAs, MSOs, vendors, or other downstream entities. Experience in a Medicare Advantage health plan, particularly a startup or rapidly growing plan. Professional Competencies The successful candidate must demonstrate: Regulatory expertise: Understands Medicare Advantage and C-SNP requirements at an operational level.

Ownership:

Personally drives compliance issues to resolution.

Attention to detail:

Can identify gaps between regulatory requirements, policy, documentation, and actual practice.

Audit readiness:

Maintains continuous readiness rather than preparing only when an audit occurs.

Cross-functional leadership:

Can hold business units accountable without relying solely on formal authority.

Judgment:

Recognizes when an issue requires immediate executive or regulatory escalation.

Execution:

Converts findings into measurable corrective actions and verifies completion.

Documentation discipline:

Ensures every material compliance requirement has an identifiable owner, evidence, monitoring mechanism, and remediation process. Key Performance Measures Performance will be measured based on, among other factors: Timely identification and remediation of compliance deficiencies. C-SNP and Model of Care compliance. CMS audit readiness and audit performance. Timely completion and validation of corrective action plans. Regulatory reporting accuracy and timeliness. Delegated entity compliance and oversight. Closure of high-risk compliance issues. Accuracy and completeness of compliance documentation. Effectiveness of ongoing compliance monitoring. Timely escalation of material regulatory risks. Accountability This position is accountable for the C-SNP compliance framework, but individual business-unit leaders remain accountable for compliance within their respective operational functions. The Compliance Officer must have sufficient authority and access to escalate material compliance concerns directly to executive leadership and the appropriate Compliance Committee or governing body. The expectation is not simply to identify compliance problems. The expectation is to identify the requirement, establish the control, assign the accountable owner, monitor performance, document the evidence, drive remediation, and verify that the issue is actually resolved. Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!

Job Type:

Full-time employment

Location:

Corporate (Huntington Beach)

Compensation Range:

$160,000.00 - $190,000.00 annually Actual compensation offered will be determined based on experience, qualifications, skills, internal equity (if available), and geographic location. This position may also be eligible for performance-based incentive compensation and benefits.

Benefits:

401(k) Paid time off (vacation, holiday, sick leave) Health insurance Dental Insurance Vision insurance Life insurance

Schedule:

Full-time onsite (100% in-office) Hours of operations: 9am - 6pm Standard business hours Monday to Friday/weekends as needed Occasional travel may be required for meetings and training sessions.

Ability to commute/relocate:

Reliably commute or plan to relocate before starting work (Required)

PHYSICAL DEMANDS

Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds. Other duties may be assigned in support of departmental goals