D-SNP Compliance Manager

KHS•Bakersfield, CA

7d•$104,899 - $133,746•Onsite

About The Position

Under the general direction of the Director of Compliance and Regulatory Affairs, the Dual Special Need Plan (DSNP) Compliance Manager will have an essential role in independently managing, analyzing, and improving the organization's compliance functions related to the Medicare (MC) Dual Eligible Special Needs Plans (D-SNPs) compliance, product, and operations. This position serves as a subject matter expert with Center for Medicare and Medicaid Services (CMS) compliance department functions, including but not limited to, regulatory and D-SNP contract review and interpretation, periodic monitoring and auditing activities based on established compliance program, policies, and practices to ensure and maintain compliance with federal, state, and local regulatory, contractual and legal requirements. Candidate will work closely with the Delegation and Oversight team to maintain alignment of MC be responsible for overseeing complex projects, conducting high-level analysis, and driving policy and process improvements across the organization.

Requirements

Bachelor's Degree Health Care Administration, Public policy, Compliance or related field or equivalent experience required
7 years’ experience in compliance to include risk assessment against contract and regulatory requirements, creation and execution of auditing, monitoring and reporting processes, administration of correction action plans, implementation of written policies and procedures, developing and delivering compliance training and education required.
3 of 7 years of managed care experience, preferably with Medicare/Medi-Cal and supervising/mentoring/leading staff required.
Experience with D-SNP SMAC, regulatory requirements and/or operations required
Medicare managed health experience required

Nice To Haves

Experience with Medicare Advantage, DSNP, or NCQA for Medicare health plans preferred.
Experience with quality improvement/process improvement techniques preferred.
Experience in Medicare Managed Care and D-SNP compliance programs (audits, risk, regulations) preferred.

Responsibilities

Assists with approval and submission of timely and accurate D-SNP State Medicaid Agency (SMAC) contract and regulatory required report deliverables not limited to MMCM, CFR and state regulations.
Conduct periodic assessments to ensure compliance against SMAC, D-SNP Policy Guide, Medicare Advantage and Prescription Drug Manuals, Part C & D reporting requirements, and other regulatory requirements.
Partner with internal stakeholders to ensure understanding of Medicare standards, timelines, and best practices.
Oversee creation and implementation of corrective action plans to reduce or eliminate risk resulting from non-compliance with DSNP regulatory requirements or performance deficiencies.
Collaborate with CMS, where applicable, to maintain/improve regulator satisfaction specific to member/provider experience and compliance with regulatory requirements.
Manage composition and delivery of inquiries and responses to state regulatory agency about D-SNP inquiries.
Actively engage in regulatory forums including dedicated state meetings specific to the DSNP.
Support responses to “request for proposals” (RFPs) and new business implementations by completing assigned compliance tasks timely and accurately.
Design, implement and improve processes to prevent, detect and respond to compliance issues and concerns related to all federal and state regulatory requirements and SMAC requirements.
Create and deliver Duals compliance training for all employees on an annual basis and as needed basis, such as in response to a compliance issue or concern.
Act as an internal consultant on integrating Medicare standards into operations, project timelines, and reporting.
Provide technical assistance and best practices to stakeholders per industry insights.
Leverage external relationships with sibling plans and consultants to inform internal strategies.
Collaborate with the Delegation Oversight and NCQA Departments r to align efforts.
Find and capitalize on synergies between Medicare and non-Medicare compliance work.
Contribute to project teams by assigning, monitoring, and guiding the work of team members.
Serve as the Compliance liaison to broader organizational initiatives and projects as needed.
Model Material Review and Submissions to appropriate state and/or federal regulators (e.g. DMHC, DHCS, and CMS)
Review and submit Marketing and communication materials to CMS.
Ensure KHS website includes required material
Assess CMS connectivity
Monitor and collaborate on CMS BID activity and submissions, in conjunction with Delegation and Oversight
Review all KHS D-SNP policies and route through policy approval process
Create Compliance Program Description, create/update Compliance policies
Review Medicare Plan Finder Preview and Part D Pricing Preview
Collaborate with Plan Benefit Package design and submit in HPMS
Collaborate on Fraud, Waste and Abuse (FWA) reporting to CMS and Department of Health Care Services (DHCS) and assist FWA team on monitoring HPMS activity surrounding FWA
Liaison between CMS Account Manager and KHS
Part C and Part D Reporting Submissions
Maintain Plan information and updates within HPMS and coordinate required CMS contract approvals
Download online enrollment center applications to provide to subcontractor daily
Evaluate HPMS memos released daily and disseminate information to applicable department for coordination, and compliance with deadlines, in conjunction with assigned compliance personnel
Notice of Intent to Apply (NOIA) submissions
Manage Inquiry escalation from CMS and DHCS for D-SNP members
Regulatory feedback to business
Serve as External Point of Contact (EPOC) to review/approve requests for Medicare Advantage (MA Rx and HPMS access)
Conduct minimum quarterly audit to validate access to CMS systems
Monitor and coordinate responses for Complaint Tracking Module (CTM), Sales Allegations, and QIO Appeals
Respond to any “Compliance Issues” received through HPMS
Maintain internal CMS Compliance Issues log, including root cause analysis, impact and corrective actions.
Coordinate self-reporting of non-compliance to the CMS Account Manager in collaboration with Compliance and Delegation Oversight leadership
Coordinate CMS Program Audits
Compile Compliance Program Effectiveness (CPE) audit deliverables and assist in representing Compliance during CMS Program Audits
Coordinate CMS Part C/D Data Validation Audits
Coordinate CMS Financial Audits
Coordinate Reviews of Plan Performance Reports
Coordinate monthly and quarterly Plan Enrollment Attestations
Coordinate annual delegation oversight audits