JOB SUMMARY

Provides strategic and operational support pertaining to health plan compliance, program integrity and Defense Health Agency (DHA) and TRICARE regulatory and URAC accreditation requirements. Supports all departments in the interpretation of regulatory requirements and development of policies and workflows that are compliant with both regulatory and corporate requirements. Manages relationships with third party vendors and contracted partners to ensure contract deliverables. Responsible for vendor training program. Manages compliance reporting hotline.

RESPONSIBILITIES

· Tracks regulatory changes that impact Plan operations inclusive of policies and procedures.

· Effectively translates regulatory requirements into streamlined operational processes to ensure compliance.

· Designs, implements, manages and ensures ongoing refinement of organization-wide strategies, programs and policies for an effective compliance program.

· Manages vendor oversight program inclusive of tracking compliance with contractual key performance indicators, development and implementation of improvement plans as need based on vendor performance, and design and delivers vendor training programs.

· Manages detailed investigations of potential/actual deviations from policy. Initiates corrective action plans and oversees to completion.

· Makes process improvement recommendations based on vendor performance, best practices and potential solutions

· Develops relationships with key stakeholders to understand processes. Proactively identifies potential risks and develops mitigation strategies.

· Prepares compliance reports for presentations to committees and senior leadership.

· Coordinates all government regulatory and compliance documents on an organizational level. Liaison for correspondence and records management.

· Manages data gathering and responses to requests for medical records, inclusive of claims summaries, in collaboration with corporate legal counsel.

· Manages annual vendor training program for both administrative and clinical vendors.

· Manages the operation of the organization’s compliance hotline. Works with corporate legal counsel and senior leadership to resolve compliance issues as appropriate.

· Aware of the potential for fraud and how to report suspected fraudulent activity.

SUPERVISORY RESPONSIBILITY

· None

EXPERIENCE

· Five to eight years of job-related management experience in the healthcare environment. Health Plan experience with regulatory policy development, investigations, and risk management preferred.

SKILLS/COMPETENCIES

· Knowledge of health care compliance policies, programs, practices, systems, related compliance issues.

· Knowledge of the elements of an effective compliance program and broad knowledge of health care industry practices and standards including both federal, state regulations and accreditation standards.

· Aware of the potential for fraud and ability to investigate suspected fraudulent activity.

· Ability to read, analyze, and interpret governmental/accreditation regulations.

· Excellent verbal and written communication skills. Ability to write reports, policies and business correspondence. Ability to communicate effectively with internal and external stakeholders.

· Meeting facilitation and presentation skills. Ability to effectively present and represent the Plan’s interests externally with regulators and internally with senior leadership.

· Problem solving skills in dealing with conflict, multiple projects, deadlines, and time constraints.

· Time management and project management skills to meet deadlines.

· Detail oriented.

· Ability to work well both independently and with others.

· Intermediate statistical analysis expertise including interpretation of data.

· Proficient with Microsoft Office – Word, Outlook, Excel, and PowerPoint; Access and Vizio a plus

· Ability and inclination to adopt technology to maximize efficiency.

Education/Certifications/License

· Associate’s degree (i.e., business management, healthcare management, informatics) OR High School diploma or equivalent and ten years directly related professional experience required

· Bachelor’s degree or Master’s preferred (i.e., business management, healthcare management, informatics)

· Certified Compliance and Ethics professional (CCEP) or Certified in Healthcare Compliance (CHC) preferred

· Ability to obtain Federal security clearance and CAC access required

Job Type: Full-time

Pay: $95,000.00 - $102,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

Work Location: In person