Duties & Responsibilities:

• Implement and direct a Compliance Program that includes training programs, and related policies and procedures for employees, agents and contractors, which complies with all applicable federal, state and local laws and regulations
• Coordinates and communicates to internal departments and external vendors, where appropriate all Medi-Cal compliance activities and programs as well as plans, implements and monitors the organization’s Medi-Cal compliance program
• Develop and implement policies and procedures to prevent and detect fraud and abuse, address specific areas of suspected fraud and abuse and initiating a corrective action plan
• Develop and implement methods and programs that encourage managers and employees to report suspected fraud and other misconduct without fear of retaliation
• Review all proposed legislation and regulations and ensure implementation of changes in law and regulation at the operation level
• Develop and implement an internal risk assessment program to inform leadership of operational risks
• Oversee CenCal Health’s Privacy Program and address any potential HIPAA privacy breaches internally or externally
• Develop and implement internal monitoring/mock audit process for all key operational areas to ensure compliance with established policies, plans, procedures and performance standards
• Ensure that internal controls are capable of preventing and detecting significant instances or patterns of illegal, unethical, or improper conduct by employees, business partners, or others working with the organization
• Oversee and coordinate all CenCal Health audits by regulatory agencies, including scheduling prep meetings, reviewing documentation to be used and ensure appropriate visibility
• Oversee and coordinate all CenCal Health Corrective Action Plans (CAP) for implementation and submission to regulatory entities
• Facilitate improvement in response to compliance audits, satisfaction surveys or other data
• Work with the General Counsel/Compliance Officer to ensure Board of Directors is informed of all compliance issues
• Report all suspected fraud and abuse to DHS and work with legal counsel and certified fraud investigators on fraud investigative activities and corrective actions
• Develop and maintain strategic relationships with regulatory agencies and key constituents relative to Regulatory Submissions, Audits and Corrective Action Plans, Delegation Oversight, Regulatory Review and Analysis
• Communicate current state of legislative issues to management and the commission recommending the organizations position. Make presentations to the Board of Directors and Executive Team on status of legislative information
• Other duties or projects as assigned.

Skills, Knowledge and Abilities:

• Knowledge of principles and techniques of administration, organization and management including in-depth understanding of the key issues that exist in the health care industry and managing a public agency
• Public relations in a governmental setting and trends in the health care industry
• Local, regional, state and federal laws, ordinances, regulations, codes, precedents, government regulations, executive orders and agency rules as they relate to managed care, Medi-Cal and other related business and polices
• Maintain confidentiality, communicate effectively with CenCal Health staff, providers, regulatory agencies and legal counsel
• Excellent written and verbal communication skills