SUMMARY
Under general supervision responsible for providing oversight and coordinating the daily operations of compliance in a manner that ensures HPSJ, regulatory and contractual requirements related to Compliance are met, including but not limited to compiling data, investigation and report of FWA (Fraud, Waste and Abuse) and HIPAA Privacy Incidents and Breaches. Work is varied and moderately complex, and requires a moderate degree of discretion and independent judgment.
SUPERVISES
Compliance Analysts.
ESSENTIAL FUNCTIONS
- Plans and assigns work; monitors department workload to ensure regulatory requirements are met; makes timely and effective adjustments.
- Identifies, monitors and analyzes appropriate metrics; develops timely and effective internal and external corrective action plans, monitoring progress and completion, coordinating interviews and document gathering; escalates as required.
- Develops, implements and maintains department policies and procedures; makes recommendations for revisions; communicates changes to appropriate individuals in a timely and effective manner.
- Responds to and resolves or facilitates understanding and compliance with regulatory, contractual and accrediting requirements, and organization policies and procedures.
- Provides guidance to internal and external stakeholders to ensure understanding and compliance with reporting and all compliance related requirements.
- Assists with the development and implementation of department-related upgrades, procedures, systems and other tools.
- Identifies, monitors and analyzes compliance programs and system processing issues; corrects or escalates as required.
- Works closely with interdepartmental units to improve workflow and processes: identifies issues and opportunities; initiates meetings; resolves issues or makes improvement recommendations as required and implement recommendations on a needed basis
- Executes and monitors business plans; assists in the development and monitoring of department budget.
- Monitors to ensure staff enters and maintains data, information, documents and files according to standards, within, but not limited to the compliance software and provide corrective actions as needed.
- Oversees research and analysis on contractual and regulatory requirements with respect to HPSJ and delegated vendors.
- Supervises and coordinates routine and ad-hoc internal and external audits and identifies gaps that require corrective action plans.
- Maintains the compliance audit program, including schedules, standards, processes, reports and tools in close collaboration with the Compliance management.
- Develops, maintains and updates master list of deliverables for required reports, materials and other items that are requested by regulators or that require regulatory approval; monitors due dates.
- Reviews deliverables for accuracy and facilitates corrections as necessary.
- Designate staff and oversee the compilation of deliverables, obtains appropriate approvals and submits deliverables according to timelines.
- Develops and maintains routine and ad hoc Compliance Reporting and monthly Dashboard, including but not limited to analysis of FWA and Privacy Incidents, detailed and summary level reporting via written interpretation of analytical results to present to internal and external stakeholders.
- Serves as the first level escalation for staff when they analyze and investigate suspected FWA and Privacy incidents for root cause, trends and tracks data to translate findings and develop processes for improvement or investigation.
- Evaluates financial impact of identified compliance issues, and reports findings if applicable.
- Adhere to HPSJ policies and procedures including departmental desktop procedures and Compliance management requirements.
- Identifies training needs and opportunities; develops and delivers routine and ad hoc department training.
- Promotes and maintains an environment that supports HPSJ’s strategy, vision, mission and values.
- Hires, supervises and retains a competent staff.
Required Skills
KNOWLEDGE, SKILLS, ABILITIES AND COMPETENCIES
Required
- In-depth knowledge of federal and state regulations and standards, including False Claims Act, Medi-Cal and DMHC/DHCS as they relate to compliance in health care.
- In-depth knowledge of managed care health plan functions and interactions as they relate to compliance.
- Strong research skills with the ability to identify and review complex materials to develop and evaluate options and propose solutions.
- Basic knowledge of ICD-10 and CPT coding and medical terminology, and industry standard payment practices.
- In-depth knowledge of data analysis and communication/reporting tools and techniques, with ability to perform analysis and resolve problems of moderate complexity, and recognize and act on trends.
- Expert knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
- Being resilient: Rebounds from setbacks and adversity when facing difficult situations.
- Optimizes work processes: Knows the most effective and efficient process to get things done, with a focus on continuous improvement; can develop, implement and maintain processes.
- Action oriented: Takes on new opportunities and tough challenges with a sense of urgency, high energy and enthusiasm.
- Directs work: Provides direction, delegates and removes obstacles to get work done.
- Plans and aligns: Plans and prioritizes work to meet commitments aligned with organization goals.
- Ensures accountability: Holds self and others accountable to meet commitments.
- Drives results: Consistently achieves results, even under tough circumstances.
- Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics.
- Courage: Steps up to address difficult issues, says what needs to be said.
- Situational adaptability: Adapts approach and demeanor in real time to match the shifting demands of different situations.
- Ability to develop, implement and maintain processes, procedures and other guidelines.
- Strong collaboration skills, including but not limited to the ability to create and foster a collaborative work environment, and organize people and resources to solve problems and identify opportunities.
- Basic knowledge of change management theory, with the ability to implement effectively.
- Ability to develop and deliver relevant and effective training and supporting materials.
- Strong oral and written communication skills with the ability to communicate professionally to diverse individuals inside and outside of HPSJ, effectively explain complex information, and conduct presentations.
- Strong interpersonal skills with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ.
- Strong project management skills and demonstrated ability to lead complex initiatives.
- Decision quality: Makes good and timely decisions that keep the organization moving forward.
- Strong supervisory and leadership skills, with the ability to supervise staff in a manner that maximizes employee performance and business results.
- Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.
- Strong mathematics skills, including the ability to calculate ratios, perform simple algebra and statistical formulas.
- Intermediate MS Word, Excel, Power Point, Visio & Project skills.
- Ability to speak and be understood in English.
- Ability to handle confidential information with appropriate discretion.
Preferred
- Basic skills in reporting software, such as Tableau, with ability to present data in consumable formats such as charts and graphs.
Required Experience
EDUCATION AND EXPERIENCE
Required
- Bachelor’s Degree
- At least two years’ experience working with Medi-Cal, Medicare or other state or federally sponsored programs in Compliance; and
- At least one year as a supervisor or two years as a lead in a substantially similar position; or
- Equivalent combination of education and experience.
Preferred
- At least three years’ experience reading, analyzing and interpreting State and Federal laws, rules and regulations and
- At least three years of experience as a compliance data analyst in a Medi-Cal managed care plan.