COMPLIANCE SPECIALIST

Summary

The Compliance Specialist is responsible for assisting in the oversight of an enterprise-wide Corporate Compliance Program to detect, correct and prevent violations of Federal and State laws, rules, or regulations. The position is responsible for assisting the Chief Compliance Officer with implementing, maintaining and monitoring the compliance program elements that includes: investigations, policies, standards, workforce training, and awareness of general compliance requirements, reporting, and investigating concerns of FWA. This position will help in the evaluation of the FWA and Compliance Program. The Compliance Specialist will report to the Chief Compliance Officer in the investigation of suspected violations and in the development and oversight of corrective action plans. The Compliance program involves a continuous process of adhering to legal, ethical and professional standards applicable to AllCare employees, Board of Governors, providers, contractors, temporary employees, consultants and subcontractors. 

The Compliance Specialist will cooperate and assist in submitting appropriate referrals and case documentation to enforcement agencies such as the Medicaid Fraud Unit (MFCU), Office of Program Integrity (OPI), Office of Inspector General (OIG), Department of Justice (DOJ), Centers for Medicaid and Medicare Services (CMS) and the Oregon Health Authority (OHA) for auditing, monitoring and oversight of external subcontractors (delegates). 

Essential Duties

1. Investigate all suspected cases of FWA.
2. Conducts investigations, utilizing data analytics, forensic tools and conduct thorough fact finding inquiries.
3. Write investigations reports to be submitted to OHA, MFCU and OPI.
4. Maintain a comprehensive knowledge of applicable federal and state laws, regulations and other requirements.
5. Assist in audits conducted by outside regulatory agencies.
6. Assist in audits conducted by AllCare Health of its subcontractor (delegates) or First Tier Entities.
7. Upholds the highest level of confidentiality in verbal, written or electronic communications pertaining to Compliance, FWA or HIPAA Privacy and Security referrals.

Job Duties

Investigations & Risk Management 

• Manage the investigative process for potential compliance violations, including fraud, abuse, conflicts of interest, and other regulatory breaches.
• Oversee the identification, reporting, and investigation of compliance concerns, and provide guidance on risk mitigation strategies.
• Utilize investigative techniques, data analytics, and forensic tools to identify suspicious activity and conduct thorough fact-finding inquiries.
• Prepare investigative reports with findings, conclusions, and recommendations for corrective actions.

Regulatory Guidance & Reporting

Act as the organizations subject matter expert on healthcare regulations, including but not limited to Stark Law, Anti-Kickback Statue, False Claims Act and others. 

• Act as the organization’s subject matter expert on healthcare regulations, including but not limited to Stark Law, Anti-Kickback Statute, False Claims Act, and others.
• Maintain a comprehensive knowledge of applicable federal and state laws, regulations and other requirements.
• Assists in conducting the annual enterprise-wide risk assessment and program evaluations.
• Assist the Chief Compliance Officer in the development of risk-based compliance monitoring work plan and protocols.
• Actively participate in the Compliance program, FWA and HIPAA Privacy & Security activities.
• Accurately log and maintain records of reported or discovered compliance concerns.
• Provide guidance to internal staff on appropriate interpretation and application of internal and regulatory policy/procedures.
• Use sound logic and reasoning to identify opportunities to improve processes.
• Effectively communicate with peers and other departments on compliance matters, work collaboratively in a team environment with a spirit of cooperation.
• Maintains punctual, regular and predictable attendance. 
• Respectfully takes directions from Chief Compliance Officer and Corporate Legal Counsel.
• Meets all required training including continuing education for certifications such as, but not limited to: CFE, CHC, AHFI, CPC, and those listed in Relias Learning Module System (LMS).
• Performs other duties as assigned.

On Call Responsibilities 

This position does not have any on call responsibilities.

Supervisory Responsibilities 

Directly supervises employees in the Compliance department. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Job Requirements:

• May require the use of personal vehicle for local travel (subject to mileage reimbursement).
• May require the use of a personal cell phone (cell phone stipend applicable).

Qualifications 

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Education & Experience

• Associates degree (AA) from a two-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience in criminal justice, fraud management, or healthcare administration.
• Work experience in investigations, with certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), Certification in Healthcare Compliance (CHC), or other fraud-related certifications,
• Knowledge of CPT Codes, ICD-10 Codes, Medicare Guidelines, OIG Work Plan priorities, Oregon Health Plan Contract Requirements, HIPAA, FWA and Compliance CFRs, Regulations and Statutes.

Certificates, Licenses, and/or Registrations

• Valid Oregon Driver’s License and vehicle insurance. 
• Certification in Healthcare Compliance (CHC). 

Language Skills

Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints. Ability to write speeches and articles using original or innovative techniques or style. Ability to make effective and persuasive speeches and presentations on controversial or complex topics to top management, public groups, and/or boards of directors.

Mathematical Skills

Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Computer Skills

Job requires specialized computer skills. Must be adept at using various applications including database, spreadsheet, report writing, project management, graphics, word processing, presentation creation/editing, communicate by e-mail and use scheduling software. 

Reasoning Ability 

Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and work with several abstract and concrete variables. 

Interpersonal Skills

• Inclusive leadership and management: Bring a clear vision and recognizes the value of divergent perspectives. Approaches leadership with mindset of “Power With” rather than 
   “Power Over” and regularly includes others in planning and decision-making. Able to make and communicate difficult decisions in the best interest of AllCare.
• Attentive, empathetic leadership: Enthusiasm for meeting and engaging with people. Able to put people at ease, especially when there are lines of difference. Listens closely to understand needs or concerns and takes steps based on that input. Gets back to people in a timely manner. Takes pride in providing clear, helpful information. 
• Proactive problem solving: Proactively develop solutions to challenges, including by constantly looking at big-picture progress and thinking about people. 
• Flexibility: Ready to take advantage of unexpected opportunities; adapts quickly to change and is a teacher to assist with change within the organization. Commits to solving unresolved issues in an effort to collaborate and model problem solving. 
• Equitable Practices translates into plans for staff development, retention, strategy, and improving culture. 

Physical Demands & Work Environment

The employee must occasionally lift and/or move up to 10 pounds. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand; walk and reach with hands and arms. The noise level in the work environment is usually moderate.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this job. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.