Under the direction of the Director of Compliance Programs and in support of the Vice President of Compliance, this position will assist in the coordination and implementation of Compliance Programs responsibilities and delegated oversight activities with contracted health plans, entities and vendors. Assist in monitoring business activities for compliance when regulations change, support departments and company strategies to ensure compliance with federal, State, and contractual healthcare requirements. Assist in audit preparation and the development of reports/tools to monitor and track implementation and completion of corrective measures. Supports the compliance team on general standards of conduct, FDR, FWA, OIG, HIPAA related matters. Cooperates with management, collaborates with cross-functional teams and performs other duties as assigned. Knowledge of Medicaid, Medicare and Medi/Medi regulations applicable to health plans and IPA’s required.
Research and interpret complex policies regarding government programs requirements and maintain tracking of all delegation oversight activities from contracted delegated health plans, entities and vendors. Coordinate strategic communications and FDR audits with delegated entities and internal business departments. Assist Director in monitoring OIG sanction checks. Ability to independently execute special assignments with general supervision. Monitor oversight and assist in ensuring compliance to regulatory standards.|Analyze and interpret health plan audits results and distribute to operational departments. Use critical judgment to work on developing improvement plans as it pertains to Medicare, Medicaid, Commercial, and Duals program corrective actions. Assist in tracking audit submissions and maintains internal documentation for consistency.|Assist Director in developing and coordinating compliance training materials for the company. Work collaboratively with all departments to follow up on audit items and ensure accuracy of information provided and timely submission, as needed.|Assist Director with documenting and analyzing changes across departmental policies when modifications are required due to audit findings and/or regulatory changes. Communicate required changes with business leads and ensure timely compliance with changes. Assist with drafting new policies and updating existing policies as required to ensure regulatory compliance.|Track and trend areas of compliance and regulatory vulnerability and risk within the organization and assist in developing solutions to enhance processes.|Assist with research and interpretation of regulatory and contractual requirements and program updates for Medicaid, Medicare and Duals programs. Work with Compliance Programs team to draft and disseminate updates and communications to business units as needed.
Minimum of three (3) years related experience in compliance, regulatory-government programs, preferably with direct experience dealing with interpreting and applying complex Medicaid and Medicare rules and policies in a healthcare administration setting. Strong computer skills, data entry, Word, Excel, Power Point and office equipment. Ability to understand and present information effectively and respond accurately to questions from business departments, outside agencies and vendors, and Management. Strong reasoning, problem-solving, project management and organization skills, with a high level of attention to detail. Excellent verbal/written communication, relationship-building and time management skills. Excellent technical writing skills with the ability to draft policies in a clear, concise manner. Ability to adapt to changing priorities and to manage various projects simultaneously. Work independently on assigned projects. Working knowledge of DHCS, DMHC and CMS requirements is required. Speak, read, and write English proficiently. Preferable experience in IPA within healthcare setting.High school diploma or GEDBachelors Degree