Job Description

The Company

At Utica National Insurance Group, 1,400 employees countrywide take our corporate promise to heart every day: To make people feel secure, appreciated, and respected.

Utica National Insurance Group is an "A" rated $2.0B award-winning, nationally recognized property & casualty insurance carrier.

Operating along the Eastern half of the United States, our Home Office is based in Central New York, with Regional Office locations in NYC, Dallas and Charlotte.

What you will do

The Examiner owns the design, execution, and continuous improvement of the organization’s Medicare compliance program and serves as the primary liaison to CMS and external regulators. Operating with a high degree of independence and authority, this role 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. This is a hybrid role reporting to our Charlotte-Ballantyne, NC; Woodbury, Long Island; or New Hartford, NY location.

Key responsibilities

• Enterprise Medicare Compliance Accountability - 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; Establishes enterprise accountability frameworks and ensures consistent compliance performance across all business units.
• CMS Audit Leadership & Regulatory Interface - 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; Interprets audit findings, drives root cause analysis, and ensures sustainable corrective actions are implemented and maintained.
• MMSEA Section 111 Governance & Data Integrity - Owns enterprise governance for Section 111 reporting, including data integrity, timeliness, and accuracy; Establishes reporting standards, internal controls, and escalation protocols; Partners with IT, Claims Operations, and vendors to resolve CMS reporting errors, rejections, and systemic data issues.
• Enterprise Compliance Program Leadership - Designs, implements, and continuously evolves the enterprise Medicare compliance program, including governance structures, controls, and reporting frameworks; Establishes policies, procedures, and best practices aligned to regulatory expectations and emerging CMS guidance; Maintains a forward-looking compliance roadmap aligned to evolving regulatory and organizational priorities.
• Claims Advisory & Financial Impact Integration - 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 subject matter expertise on Medicare Set-Asides (MSAs), settlements, and post-settlement compliance obligations.
• Enterprise Governance & Matrix Leadership - Leads cross-functional Medicare compliance governance across Claims, Legal, IT, Finance, and external vendors; Establishes enterprise compliance standards and holds business units accountable for adherence and performance outcomes; Provides oversight and direction to QA resources, audit functions, and vendor partners supporting compliance activities.
• Quality Assurance & Continuous Improvement - Directs risk-based quality assurance reviews focused on Medicare compliance within the Workers’ Compensation portfolio; Identifies systemic risks, trends, and control gaps, driving enterprise-level process improvements; Ensures ongoing alignment between claims handling practices and regulatory requirements.
• Reporting, Analytics & KPI Ownership - Accountable for enterprise Medicare compliance KPIs, including reporting accuracy, audit findings, remediation cycle time, and error rates; Develops executive-level dashboards and provides reporting to Claims Leadership and ELT; Tracks and communicates the financial impact of compliance performance, including penalty avoidance and risk exposure reduction.
• Performs other duties as assigned.
• Conforms with all corporate policies and procedures.

What you 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.

Salary range: $93,000 - $136,500

The final salary to be paid and position within the internal salary range is reflective of the employee’s work experience, their geographic location, education, certification(s), scope and responsibilities in the role, and additional qualifications.

Benefits

We believe strongly that talented people are core to our success and are attracted to companies that provide competitive pay, comprehensive benefits packages, career advancement and challenging work opportunities. We offer a Comprehensive Benefits Plan for full time employees that include the following:

• 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

Additional information

This position is a full time salaried, exempt (non overtime eligible) position.

Utica National is an Equal Opportunity Employer.

Apply now and find out what it’s like to be a part of an amazing team, thrive in an exciting environment and work for a company you can be proud of. Once you complete your application, you can monitor your status in the hiring process by logging into your profile. A representative from our Talent Acquisition team will be in touch regarding any change in your candidacy.

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