ACA Compliance Program Manager PCHP

Parkland Health

4d•Hybrid

About The Position

Parkland Community Health Plan’s Program Manager, ACA, ensures that PCHP complies with applicable laws, regulations, and internal policies. The role develops and implements compliance policies and procedures, conducts audits, supports employee training, manages relationships with regulatory agencies, and leads compliance investigations. It ensures that products and services are tested against program, insurance, and business-entity regulatory requirements. The manager oversees compliance across the ACA product line, including QHP certification and renewal, regulatory reporting, risk assessment, delegated-entity oversight, member-facing materials, complaints and appeals, audits, and ACA-specific training. The position also provides guidance to departments on new and changing requirements and supports a culturally welcoming, ethical, and inclusive work environment. This is a hybrid, full-time day position, scheduled from 8 a.m. to 4 p.m., Monday through Friday.

Requirements

Bachelor’s degree in business, public health, health policy, health care administration, legal studies, or a related field.
At least 5 years of directly related experience in managed care operations, health care compliance, and related legislative and regulatory research, or an equivalent combination of education and related experience.
Experience administering, managing, and overseeing ACA products and plans, with a focus on contract compliance, audits, corrective action plans, and risk management.
Experience developing, implementing, or administering compliance education and training specific to ACA regulatory requirements.
Demonstrated knowledge of relevant federal and state government regulations, guidelines, and CMS and TDI reporting requirements for administration and oversight of ACA products and plans.
Strong analytical, critical-thinking, and problem-solving skills, attention to detail, and ability to interpret complex regulatory language, identify risks, assess cross-functional impacts, and recommend resolutions.
Strong communication skills, including professional interaction with federal and state regulatory agencies in a managed care or insurance environment.
Ability to collaborate with diverse stakeholders across the organization.
Ability to lead and work independently and as part of a team.
Skill in developing and implementing corrective action plans.
Ability to manage multiple deadlines and time constraints.
High proficiency in Microsoft Word, Excel, and PowerPoint.
Strong legal and regulatory knowledge, risk-management, policy-development, investigative, or fraud, waste, and abuse detection experience, and effective stakeholder collaboration and communication.

Nice To Haves

Master’s degree in business, public health, health policy, health care administration, legal studies, or another related advanced field.
Certified in Healthcare Compliance (CHC) from the Health Care Compliance Association (HCCA).
Certified Compliance and Ethics Professional (CCEP) from the Society of Corporate Compliance and Ethics (SCCE).
Certified Professional Compliance Officer (CPCO) from the American Association of Procedural Coders (AAPC).

Responsibilities

Maintain and track federal and state laws, regulations, sub-regulatory guidance, contract documentation, amendments, and key compliance measures affecting the ACA product line.
Provide compliance oversight of sales, marketing, agent and broker activities, quality, provider and network management, clinical operations, utilization management, claims, premium billing, enrollment and eligibility, and member services.
Manage and support annual QHP certification, recertification, and renewal, including CMS plan and benefit data submissions, essential health benefits, actuarial value reviews, and coordination of TDI form and rate filings.
Coordinate and monitor federal and state regulatory reporting and data submissions, including medical loss ratio reporting, risk adjustment, transparency in coverage reporting, and other CMS and TDI reports.
Develop policies, procedures, and processes for annual stakeholder review of policies to ensure compliance with federal and state program regulations.
Advise departments on compliance issues and implementation of changing ACA requirements, including benefit and payment parameter changes, QHP certification standards, and state regulatory and contract language.
Conduct compliance audits and monitoring of ACA operations and delegated entities; develop and implement corrective action plans; and support readiness for CMS program audits, HHS-RADV audits, and TDI market conduct examinations and complaint inquiries.
Perform risk assessments; identify and report emerging trends, deficiencies, and variances to appropriate departments and teams.
Review ACA member-facing and marketing materials, including SBCs, evidence of coverage, renewal and discontinuation notices, and required member notices, for regulatory compliance.
Monitor ACA complaint, appeal, and external or independent review organization processes for compliance with requirements and timeframes.
Support oversight of delegated vendors and first-tier, downstream, and related entities performing ACA functions, including due diligence, monitoring, and corrective-action follow-up.
Provide ACA- and Marketplace-specific compliance training to employees, non-employees, and delegated entities as appropriate or required.
Provide mentoring and guidance within the department as appropriate.
Promote a culturally welcoming and inclusive work environment and act with integrity while adhering to Parkland’s mission, vision, values, policies, procedures, and guidelines.
Complete assigned training, self-appraisal, and annual health requirements on time; adhere to hybrid work requirements; attend required meetings and town halls; and communicate ethical or legal concerns through established channels.
Complete projects and assignments independently and on time, respond to information requests promptly, and maintain confidentiality.
Perform other work reasonably related to the position, qualifications, and competencies.
Identify process and customer-satisfaction improvements, make recommendations to a supervisor, and implement and monitor results as appropriate.
Stay current with developments and trends in the field through professional learning and participation, and integrate relevant knowledge into work practices.
Maintain knowledge of applicable rules, regulations, policies, laws, and guidelines; develop effective internal controls; and seek guidance as needed.