Compliance Delegation Specialist II - 25-227

PriMed Management Consulting • San Ramon, CA

11d • $75,000 - $82,000

About The Position

The Compliance Delegation Specialist II is a member of the Compliance Department. Under the direction of the Manager of Compliance Delegation and in support of the Compliance Officer, this position will assist in the coordination and implementation of Compliance Delegation Program responsibilities and delegated oversight activities with contracted health plans, entities, and vendors. Assist in monitoring business activities for compliance when regulations change, support departments, and company strategies to ensure compliance with federal, state, and contractual healthcare requirements. Assist in delegation audit preparation and developing reports/tools to monitor and track the implementation and completion of corrective measures. Supports the compliance team on general standards of conduct, FDR, FWA, OIG, HIPAA related matters. Knowledge of Medicaid/Medi-Cal, Medicare, and Medi/Medi regulations applicable to health plans and IPA’s required. Additionally, the Compliance Delegation Specialist II is responsible for establishing and maintaining collaborative, courteous, and professional relationships with health plan representatives as well as interdepartmentally within PriMed/Hill Physicians. Cooperates with management, collaborates with cross-functional teams, and performs other duties as assigned. The responsibilities below will be carried out and managed under the guidance and supervision of the Manager of Compliance Delegation.

Requirements

• Bachelor’s Degree or equivalent experience required.
• 5 Plus years of experience with managed healthcare and/or health plan audit and compliance.
• Knowledge of NCQA, CMS, DMHC, DHCS, California Health and Safety Codes.
• Knowledge of and direct experience with federal and state fraud, waste and abuse (FWA) laws.
• Communication and ability to explain complex topics (verbal and written).
• Courteous and professional communication, collaboration, and ability to work with all levels of the organization and Health Plans.
• Excellent analytical, time management, leadership, and interpersonal skills.
• Focus on service with excellent time management, organizational, analytical, and interpersonal skills.
• Advanced with Adobe and Microsoft Applications. (Outlook, Word, Excel, PowerPoint, Project, SharePoint, etc.)
• Analytical thinking to draw conclusions and critical thinking using logical reasoning to find solutions.
• Knowledge in Technology, system utilization, automation, privacy, and security.
• Proficient Project Management skills with attention to details.
• Outstanding communication skills and ability to work with all levels of the organization.
• Sound decision-making ability.

Nice To Haves

• Familiar with Medicare and Medicaid/Medi-Cal programs preferred.

Responsibilities

• Administrative: Proficient in Microsoft products (Outlook, Word, Excel, and PowerPoint) and Adobe. Utilizes and Maintains SAI360 Audit Management – External Audit Module and make recommendations to Compliance Delegation Manager and Compliance Officer as needed. Conduct and quality check monthly delegation reports timely and accurately. Ensure that Compliance Teams, Supervisors, and the Manager of Compliance Delegation are consistently kept informed and updated timely. Availability before and after business hours to support compliance department functions, and business needs. Attend calls, meetings, and other education sessions, as well as research and keep up to date on Health Plan requirements as they relate to PriMed/Hill Physicians. Receive, track, coordinate and monitor health plan and third-party emails for delegation audit process, requests for information, and correspondence between Health Plans, third parties, and PriMed. Assist with other functions as needed.
• Delegation Audits: Conduct research for assigned tasks and inquiries for delegation audits related to utilization management, claims, credentials, and other audit areas as assigned to support business needs. Prepare delegation audit tasks, including assessing that the request meets the delegation audit scope and delegation/contractual agreements. Tasks include but limited to documentation gathering, file pulls, policy and procedures pulls and reviews, and preparing documents for the delegation audits, reviewing that all responses are fact-based, appropriate, and addressing the request. Prepare for and assist Manager with the response for health plan delegation audits, meeting or speaking with delegation auditors, facilitating the delegation audit process, and participating in exit interviews and follow-up. Ensure that all your deliverables are submitted in a timely manner; tracked and documents are appropriate. Ensure remediation response of any non-compliant findings address the findings. Supporting evidence is appropriate and delivered to the requester timely. Critical thinking for all communications are clear, concise and timely. Deliver supporting evidence demonstrating implementation to health plan partners or third parties when requested. Analyze and interpret health plan audits results and distribute them to operational departments. Track and trend all health plan audit findings, collaborate with operational departments to implement strategies for future risk mitigation and improvement as it relates to those findings. (i.e. in the following areas: claims, pre-delegation audits, credentialing, provider access and availability survey results, and utilization management.) Collaboratively work with any impacted departments. Work with relevant operational departments to develop and implement health plan audit readiness strategies. Present delegation or agency audit results (findings/corrective action plans (CAPs) to operational departments. Publish delegation audit results internally as a resource for interdepartmental process improvement and/or best practice examples.
• Regulations/ Guidelines/ Delegation Agreements: Review of new regulations, guidelines, and delegation agreements and updates to determine coordination with the impacted operational departments. Provide an overview and ensure operations teams are familiar with the regulation and understand their respective obligations by required deadlines. Ensure policies and procedures, or other supporting documents are created for the implementation of the new regulation.
• Letters: Assists in the template/letter production process, including finalization of letters. Assists in the maintenance of letter templates by the Health Plan in the systems including initiation request for update, tracking, testing and finalization into production.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 501-1,000 employees