Job Summary

This position is responsible for leading the execution of Medicaid and Medicare compliance strategy and activity across the organization. Primary duties include technical and operational planning and oversight, as well as resource, relationship, and people management. This position provides input into strategic plans for the broader organization.

Essential Responsibilities

Technical/Operational Leadership

• In coordination with the VP of Audit and Compliance, directs compliance activities across the organization in support of Medicaid, Medicare, and other populations.
• Ensures the development and operation of an effective compliance program in accordance with CMS requirements and the Federal Sentencing Guidelines, including:
  • Monitoring to ensure effective written compliance policies and procedures and Standards of Conduct
  • Periodic reporting to the organization's Internal Compliance Committee (senior management) and governing Board of Directors; serve as the Internal Compliance Committee Chair
  • Providing effective training and education
  • Establishing and maintaining effective lines of communication at all levels of the organization (to include a non-compliance reporting hotline)
  • Ensuring consistent enforcement of well-publicized disciplinary standards
  • Developing and maintaining an effective system for routine monitoring, auditing and identification of compliance risks
  • Collaborating with other departments to direct compliance issues to appropriate existing channels for investigation and resolution; consults with external attorneys as needed to resolve difficult legal compliance issues
  • Ensuring there are clear and specific disciplinary policies, procedures, and standards
• Develops and monitors an annual compliance work plan.
• Reviews and leads the implementation of new requirements outlined by CMS and OHA.
• Acts as the primary leader to plan all meetings with external regulatory sources and oversees the organizational compliance calendar.
• Ensures the development of sufficient and accurate compliance dashboards used to identify and monitor current compliance and compliance trending of all operational activities.
• Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in the future.
• Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
• Provides oversight of the development and maintenance of policies, procedures, structures, and training to support the staff and department into the future.
• May serve as a sponsor or chair for key projects and initiatives.

Strategic/Operational Planning

• Participates in the development of vision, goals, and strategic plans for Audit and Compliance.
• Provides input into the strategic plans of the organization.
• Develops short and long-term plans and policies; oversees the development and execution of standard operating procedures.
• Maintains a business unit view while establishing department priorities, being cognizant of broader business unit and organizational impacts.

Financial/Resource Management

• Recommends budgets in alignment with short- and long-term plans.
• Manages resources to ensure priorities are accomplished.
• Approves resource allocations within budget, including people, finances, and timelines; make decisions on exceptions.

Relationship Management

• Leads effective communication system for work group(s), ensuring a collaborative culture.
• Builds and ensures effective relationships across internal teams and external organizations for current or future integration.
• Partners with internal leaders and managers in identifying improvement plans and processes.
• Represents CareOregon in external meetings and functions, providing productive leadership presence and effectiveness.

Employee Supervision

• Directs team(s) and establishes team direction and goals in alignment with the organizational mission, vision, and values.
• Identifies work and staffing models; recruits, hires, and oversees a team to meet work needs, using an equity, diversity, and inclusion lens.
• Identifies department priorities; ensures employees have information and resources to meet job expectations.
• Leads the development, communication, and oversight of team and individual goals; ensures goals, expectations, and standards are clearly understood by staff.
• Manages, coaches, motivates, and guides employees; promotes employee development.
• Incorporates guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, budgeting, resource allocation, and decision making.
• Ensures team adheres to department and organizational standards, policies, and procedures.
• Evaluates employee performance and provides regular feedback to support success; recognizes strong performance and addresses performance gaps and accountability (corrective action).
• Performs supervisory tasks in collaboration with Human Resources as needed.

Organizational Responsibilities

• Perform work in alignment with the organization's mission, vision and values.
• Support the organization's commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
• Strive to meet annual business goals in support of the organization's strategic goals.
• Adhere to the organization's policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Experience and/or Education

Required

• Minimum 10 years' experience in regulatory, compliance, and/or audit, including at least 8 years' experience in healthcare

Preferred

• Minimum 4 years' experience in a supervisory position
• Leadership experience in a managed care organization

Knowledge, Skills and Abilities Required

Knowledge

• Knowledge of managed healthcare operations
• Knowledge of State and Federal compliance plan requirements for Medicare and Medicaid Programs
• Knowledge of HIPAA Privacy and Security laws, practices, access, release information and release control technologies
• Knowledge of the Patient Protection and Affordable Care Act
• Knowledge of OAR's and their purpose
• Basic understanding of information systems
• Knowledge about how the functions of a business work and relate to one another

Skills and Abilities

• Ability to perform or oversee the performance of risk assessments and/or gap analysis

• Ability to facilitate learning opportunities in a variety of informal and formal settings
• Ability to make presentations to small and large groups
• Ability to think logically and creatively without undue influence from personal biases
• Ability to build conceptual models and communicate complex ideas effectively
• Ability to plan, organize, manage, and monitor work projects
• Excellent written and verbal communication skills
• Investigative skills
• Strong interpersonal skills

• Ability to work effectively with diverse individuals and groups

• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to for at least 3-6 hours/day

Working Conditions

Work Environment(s): Indoor/Office Community Facilities/Security Outdoor Exposure

Member/Patient Facing: No Telephonic In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment

Travel: May include occasional required or optional travel outside of the workplace; the employee's personal vehicle, local transit or other means of transportation may be used.

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.

Veterans are strongly encouraged to apply.

We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.

Visa sponsorship is not available at this time.