Description

POSITION SUMMARY

Under the supervision of the Compliance and Ethics Officer (“CO”) and other Compliance Department staff as applicable, help ensure Community Health Group (“CHG”) complies with applicable federal, State, and local laws, regulations, and contract requirements through the creation and maintenance of an effective compliance program.

COMPLIANCE WITH REQUIREMENTS

Comply with all applicable legal and compliance requirements, including but not limited to federal and State laws and regulations; privacy, confidentiality, and information security mandates; and CHG policies and procedures.

POSITION DUTIES

• Assist in the management of day-to-day operations of the Compliance Department.

• Contribute to the achievement of established Department goals and objectives and adhere to Department policies, procedures, and standards.

• Organize and maintain inventory of Compliance Department policies and procedures.

• Maintain a strong working knowledge of all applicable legal, regulatory, contractual, and accreditation requirements. Update job knowledge by participating in educational opportunities and reading professional publications.

• Perform special projects as requested.

• Discharge other duties as may be required in the course of business or as may be assigned by the CO.

First Tier Downstream and Related Entities (“FDR”) Oversight Program

• Under the direction of the CO, timely and comprehensively coordinate and perform all FDR audits, investigations, CAPs, education and training, and Program development and risk management.

• Work with all CHG stakeholders to ensure the FDR Oversight Program requirements are accomplished in a timely, comprehensive, and effective manner, in accordance with CHG’s FDR policies and procedures, and in compliance with applicable State and federal regulations, Centers for Medicare and Medicaid Services (“CMS”) contractual requirements, including CFR Title 45 and other applicable legal and regulatory requirements.

• Track and provide FDR Oversight Program reports on a regular basis, and as directed or requested.

Fraud Waste and Abuse Prevention and Detection Program (“FWA Program”)

• Under the direction of the CO, timely and comprehensively coordinate, monitor, and perform duties related to CHG’s FWA Program, including investigations, CAPs, education and training, and FWA Program development and risk management. Work with Compliance Department stakeholders as needed to accomplish these tasks.

• Work with all CHG stakeholders to ensure the FWA Program requirements are accomplished in a timely, comprehensive, and effective manner, in accordance with CHG’s FWA policies and procedures, and in compliance with applicable State and federal regulatory, legal, and contractual requirements.

• Track and provide FWA Program reports on a regular basis, and as directed or requested.

Privacy Compliance Program

• Under the direction of the CO, timely and comprehensively coordinate and assist in the implementation and maintenance of the Compliance Program.

• Assist in the investigation of potential privacy incidents.

Regulatory Affairs

• Support the Regulatory Affairs Manager in timely and comprehensively coordinating and performing all CHG regulatory reporting, including with the Department of Managed Health Care (“DMHC”) and the Department of Health Care Services (“DHCS”).

• Assist with and track responses to regulatory inquiries, investigations, data, and other requests.

• Under the direction of the CO assist with the coordination of the CMS, DMHC and DHCS audits.

• Serve as one of CHG’s Compliance Department liaisons with regulatory agencies, including for responses to State inquiries, audits, and report requests. Assist in the drafting and review of responses to regulatory agencies.

ADMINISTRATION AND MANAGEMENT

• Not applicable.

Qualifications

Education

• Bachelor’s Degree in compliance, health policy, health administration, legal or regulatory affairs, or other related discipline strongly preferred. Managed health care management experience may be considered in lieu of academic training.

• Certification in Healthcare Compliance (“CHC”) from the Health Care Compliance Association is preferred.

Experience/Skills

• Minimum four or more years’ experience in auditing, compliance, legislative affairs, regulatory affairs, or public policy analysis preferred.

• Four or more years in a managed care setting strongly preferred.

• Customer service skills with the ability to interact professionally and effectively with all stakeholders.

• Excellent written and verbal communication skills and detail oriented.

• Understanding of NCQA, State/Federal legislative and regulatory processes, health plan operations, and the relationships between departments and functional areas.

• Hands on compliance implementation experience with health care industry statutory, regulatory, and/or accreditation requirements, preferably with CMS, DMHC, and/or DHCS.

• Demonstrated ability to utilize and apply internal compliance auditing principles, practices, and techniques.

• Strong abilities to organize and prioritize work effectively; manage projects; and apply established policies procedures and guidelines for problem-solving and decision making.

• Ability to maintain confidentiality and comply with applicable privacy and confidentiality requirements.

• Intermediate to advanced level proficiency with MS Office applications (Word, Excel, PowerPoint, Access), expertise with graphics and presentation software.

• Strong attention to detail.

Physical Requirements

• Prolonged periods of sitting.

• Some travel, including driving within the County of San Diego.

**Must have current authorization to work in the USA**

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.