DEPARTMENT(S):  Office of Compliance REPORTS TO:  Executive Director, Compliance FLSA STATUS:  Exempt SALARY GRADE:  R - $144,000 - $204,000

JOB SUMMARY

The Director’s responsibility is to ensure that CalOptima and its subcontracted health networks comply with appropriate standards, regulations, contractual provisions, federal waivers, and laws.  The position serves as the Privacy Officer responsible for Health Insurance Portability and Accountability Act (HIPAA) compliance with the Privacy Rule. The incumbent oversees compliance activities and processes for CalOptima, including CalOptima Direct and its subcontracted health networks in relation to Fraud, Waste, and Abuse (FWA). The Director will interact with CalOptima executive, departmental management, health network management, legal counsel, as well as state and federal representatives and others as required. 

POSITION RESPONSIBILITIES:

• Plans, develops, and implements strategies, processes, policies, procedures, and other activities to ensure CalOptima, as well as its subcontracted health networks, follow state and federal standards and requirements.
• Develops and implements the Fraud, Waste and Abuse program at CalOptima. Interfaces with state and federal program integrity units to ensure enforcement of all provisions of the program.
• Develops and implements plans for prospective and retrospective FWA avoidance, detection, investigation, and recovery.
• Implements plans to remediate FWA and to maximize recoveries related to FWA, with a demonstrated ability to achieve results.
• Monitors compliance with company policies, procedures, and compliance with pertinent FWA provisions of state contracts.
• Coordinates investigative activities with other departments, providers, members, vendors, regulatory, and law enforcement agencies.
• Assists in the development and presentation of FWA training processes.
• Oversees focused audits or reviews activities as required, analyzes results, and makes recommendations to executive staff regarding corrective actions and/or penalties, or other activities that may be necessary to address issues.
• Oversees the implementation of corrective action plans, monitor internal staff, or health networks to ensure appropriate compliance with corrective action plans, and make recommendations for their completion.
• Establishes processes for tracking and reporting disclosures of Protected Health Information (PHI) as required by the privacy rule.
• Assists with the development of contractual language, policies and procedures, guidelines, standards, or other requirements to ensure appropriate compliance to regulatory or other requirements.
• Serves as the HIPAA Privacy Officer and is responsible for ensuring compliance with all HIPAA privacy rules, and any other privacy statutes and regulations. These activities include development and implementation of privacy policies, procedures, and practices, including training, communication, compliance monitoring, handling of complaints and compliance issues, and resolving any issues involving the use or disclosure of PHI.
  • Develops mechanisms to monitor CalOptima’s application of its privacy policies including its compliance with these policies.
  • Collaborates with Information Services to determine appropriate levels of user security access and assist in the monitoring of this access where necessary.
  • Develops mechanisms to limit access to PHI and to identify any unnecessary collection of PHI through ongoing monitoring processes.
  • Develops and monitors the process for reviewing requests to use PHI.
• Reviews new or modified HIPAA regulations and related laws to determine if policy modifications are required and performs initial and periodic privacy gap and risk assessments.
• Interacts with and responds to state and federal regulators and representatives, on compliance-related issues.
• Works with all organizational personnel involved with any aspect of release of PHI to ensure full coordination and cooperation pursuant to the policies and procedures and legal requirements.
• Coordinates with the Security Officer to integrate privacy assessment, planning, policies and procedures with the related security efforts, and reports to senior management on new privacy legislation and regulations.
• Establishes and administers processes for receiving, investigating, acting on, and documenting all complaints related to the organization’s privacy policies and procedures in coordination with others such as department managers, Human Resources, and legal counsel.
• Other projects and duties as assigned.

POSSESSES THE ABILITY TO:

• Evaluate, analyze regulations, interpret significance, and recommend policies to comply, apply, and ensure compliance to applicable regulations.
• Persuade and instill effective cooperation and compliance. Develop rapport and facilitate cooperation, as well as apply sanctions or corrective actions.
• Coordinate effectively with various departments, as well as develop and prepare coordinated responses and ensure uniformity and continuity.
• Communicate clearly and concisely, both verbally and in writing
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

EXPERIENCE & EDUCATION:

• Bachelor’s degree in Public Policy, Public Administration, Health Care Administration, or related field or equivalent work experience required.
• 5 years of experience at a responsible level in a Managed Care organization and interacting with governmental requirements and regulations required.

PREFERRED QUALIFICATIONS:

• Master’s degree in in Public Policy, Public Administration, Health Care Administration, or related field preferred.
• Experience in conducting investigations preferred.
• Experience in analyzing and interpreting data preferred.
• Experience in developing and delivering educational presentations preferred.
• Medi-Cal experience highly preferred.

KNOWLEDGE OF:

• Managed care and compliance with Fraud, Waste, and Abuse.
• Effective contracting and monitoring of the application of contracts.
• Federal and state regulation and other requirements and practices related to Medi-Cal/Medicaid, Title 22, Knox-Keene, as well as other governmental and public sector operations and practices.
• Effective methods and techniques for persuasion and enforcement, compliance, and effecting change.
• Managing staff and coordinating the work of interactive groups.
• HIPAA regulations, related federal and state laws, and health care accreditation standards.

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

_ _

_ If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.  You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134._

Required Skills Required Experience