Overview

To develop and implement long-term quantitative analysis strategies to meet NCQA and DHCSstandards for reporting. To perform, and assist in the performance of, duties that ensure theaccuracy, completeness and truthfulness of enterprise wide regulatory reporting including all data,information and documentation submitted to PHC’s governing agencies. Works collaborativelywith all PHC department subject matter experts (SME) to implement new regulatory reportingrequirements or templates and assist in troubleshooting regulatory reporting issues. To developand implement strategies to meet NCQA standards for the oversight of delegate reporting.Supports the plan-wide Privacy and Fraud, Waste and Abuse (FWA) program by preparing trendanalysis, forecasting reports and managing data collection in EthicsPoint.

Responsibilities

• Responsible for independently validating the accuracy of regulatory reports submitted tothe Regulatory Affairs and Compliance (RAC) unit by department SMEs or delegates toensure reporting is in conformance with the regulatory agencies reporting template andcontains the required attributes specified in reporting instructions prior to filing with PHC’sgoverning agencies.
• Develops and maintains working knowledge of PHC’s governing agencies reportingrequirements and NCQA standards for the oversight of delegation reporting to work withkey department SMEs to support compliance with all reporting requirements and NCQAstandards and assist in troubleshooting regulatory reporting issues.
• Project/program involvement will include working with department SMEs to implement newreporting requirements for new programs and benefits including DHCS Drug Medi-Cal andCCS Whole Child Model.
• Communicate regulatory reporting changes to existing regulatory reporting templates orother reporting requirements to all department SMEs and the Delegation Oversight unit andwork with affected departments to implement changes.
• Works closely with department SMEs and Delegation Oversight unit to resolve anyregulatory report quality issues.
• Serves as primary contact for internal and external regulatory reporting related inquiries.
• Maintain PHC’s Regulatory Reporting Calendar, Master List Tracking Sheet and DataCertification
• Serves as an active contributor in data quality or analytic workgroups and assist indeveloping data governance and data quality issue resolution, streamline reporting toreduce unnecessary duplication; ensures consistent and accurate use of regulatory datareporting.
• Under the direction of the Regulatory Affairs Manager, works on analyzing and documentingcurrent processes to determine process needs that will improve the performance and/orincrease efficiency within the unit.
• Assist in developing or updating RAC’s processes including policies and procedures,desktop procedures, workflows, best practices and training materials.
• Develop quantitative and trending reports for Privacy and FWA reported incidents viaEthicsPoint advanced analytic tools.
• Enhance current tracking and trending mechanisms to consolidate into EthicsPoint.
• Prepare and distribute standard daily, weekly, monthly and quarterly reports and presentPrivacy and FWA statistic reports to the PTAS and FWA workgroups or ComplianceCommittee as a backup for the Regulatory Affairs Manager.
• Provide back up and support to Regulatory Affairs Specialist as required in Privacy andFWA investigations, including creating randomized data sampling or other analysisrequired.
• Research complex regulatory related inquires, provide accurate and timely responseutilizing all applicable State and Federal regulations.
• Supports compliance training program.
• Supports internal and external audits
• Participates in special projects and assignments as needed
• Other duties as assigned.

Qualifications

Education and Experience

Bachelor’s degree in relevant field; two – three (2-3) years of experiencein the health care field, managed care experience preferred; must haveknowledge of regulatory related reporting requirements and Medi-Calregulations; experience with data analytics and forecasting trendspreferred; or equivalent combination of education and experience.

Special Skills, Licenses and Certifications

Highly proficient in applicable business software applications includingPC usage, Microsoft Word, PowerPoint, Excel, Visio, SharePoint, typingspeed 45 wpm. Valid California driver’s license and proof of currentautomobile insurance compliant with PHC policy are required to operatea vehicle and travel for company business.

Performance Based Competencies

Excellent oral and written communications skills. Excellent organizationskills with ability to prioritize assignments, and maintain effective filingsystems. Ability to work under minimal supervision and exerciseexcellent independent judgement. Diplomacy and tact in handlingsensitive information regarding personnel affairs as required. Ability tointeract with executives and vendors effectively, handling allassignments with efficiency. Must be able to work well under pressure,handle multiple tasks and meet deadlines under short turnaround timesor tight timeframes.

Work Environment And Physical Demands

Ability to use a computer keyboard and other business machines. Morethan 50% of work time is spent in front of a computer monitor. Whenrequired, ability to move, carry, or lift objects of varying size, weighingup to 35 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$ 79,273.96 - $ 103,055.85

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.