Medicare Compliance, Workers' Compensation Quality Assurance Examiner

Utica National Insurance Group

Compliance Examiner managing Medicare compliance and serving as CMS liaison at Utica National Insurance Group. Lead governance and oversight across various business units to ensure compliance standards are met.

Posted 6/23/2026full-timeCharlotte • New York, North Carolina • 🇺🇸 United StatesSeniorLead💰 $93,000 - $136,500 per yearWebsite

About the role

Key responsibilities & impact

Owns the design, execution, and continuous improvement of the organization’s Medicare compliance program and serves as primary liaison to CMS and external regulators.
Provides enterprise governance, oversight, and matrix leadership across Workers' Compensation Claims, Legal, IT, Finance, and vendor partners to ensure compliance standards are consistently executed and sustained.
Accountable for enterprise Medicare compliance performance, including CMS audit outcomes, Section 111 reporting accuracy, and adherence to MSP and MSA requirements.
Owns mitigation of financial and regulatory exposure, including avoidance of CMS penalties, reporting inaccuracies, and settlement compliance deficiencies.
Serves as the primary enterprise liaison to CMS and applicable regulatory bodies, leading all audit-related interactions, inquiries, and dispute resolution.
Defines and executes enterprise CMS audit strategy, including preparation, response, and remediation execution.
Drives root cause analysis and ensures sustainable corrective actions are implemented and maintained.
Establishes reporting standards, internal controls, and escalation protocols.
Partners with Claims Leadership and Legal on complex and high-exposure Workers’ Compensation claims involving Medicare beneficiaries.
Influences settlement strategy to ensure Medicare interests are protected while optimizing financial outcomes and minimizing exposure.
Provides oversight and direction to QA resources, audit functions, and vendor partners supporting compliance activities.

Requirements

What you’ll need

Bachelor's Degree preferred.
7-10 year's experience in Workers’ Compensation claims, Medicare compliance, regulatory oversight, or quality assurance within a Property & Casualty environment.
Demonstrated experience leading CMS audits and/or Section 111 reporting programs at an enterprise level.
Proven ability to operate in a strategic, cross-functional leadership role without direct authority.

Benefits

Comp & perks

Medical and Prescription Drug Benefit
Dental Benefit
Vision Benefit
Life Insurance and Disability Benefits
401(k) Profit Sharing and Investment Plan (Includes annual Company financial contribution and discretionary Profit Sharing contribution based upon annual company financial results)
Health Savings Account (HSA)
Flexible Spending Accounts
Tuition Assistance, Training, and Professional Designations
Company-Paid Family Leave
Adoption/Surrogacy Assistance Benefit
Voluntary Benefits - Group Accident Insurance, Hospital Indemnity, Critical Illness, Legal, ID Theft Protection, Pet Insurance
Student Loan Refinancing Services
Care.com Membership with Back-up Care, Senior Solutions
Business Travel Accident Insurance
Matching Gifts program
Paid Volunteer Day
Employee Referral Award Program
Wellness programs
Personal insurance discount

ATS Keywords

✓ Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

Medicare complianceCMS audit strategySection 111 reportingroot cause analysisinternal controlsfinancial exposure mitigationregulatory oversightquality assurancesettlement complianceWorkers' Compensation claims

Soft Skills

leadershipstrategic thinkingcross-functional collaborationinfluencecommunicationproblem-solvingnegotiationreporting standards establishmentdispute resolutionoversight

Certifications

Bachelor's Degree