Director of Compliance - Aspire Health Plan

Montage Health•Monterey, CA

2d•Hybrid

About The Position

Aspire Health Plan is seeking a Director of Compliance to fulfill its commitment to compliance by planning, designing, implementing, and refining the Compliance Program. This role involves developing standards, coordinating training, conducting audits, identifying and resolving compliance issues, and promoting ethical practices consistent with the mission and values of Aspire and legal requirements. The Director will serve as a primary contact with CMS and the Department of Managed Health Care (DMHC) in California, monitor regulatory obligations, and ensure compliance with HIPAA. Key responsibilities include developing training, submitting state and federal filings, creating risk assessments, managing policies and procedures, coordinating FWA investigations, and preparing compliance reports for the Board of Directors and Executive Management. The role also involves monitoring the effectiveness of the Compliance Program and preparing annual budgets and operational plans.

Requirements

A minimum of 7 years’ experience working in health plans is required.
3-5 years management experience.
A strong background in Internal Audit techniques, practices and theories.
Thorough understanding of effective internal audit guidelines and reporting requirements.
A strong background in HIPAA and FWA practices and regulations.
Strong knowledge of California Commercial health plans, Medicare Advantage/Part D, and NCQA guidelines, with demonstrated experience in managed care contracting and state/federal and accrediting body reporting requirements.
Ability to collaborate with all levels of management and staff.
Able to successfully manage multiple priorities and assignments.
Outstanding communication skills, both written and verbal; interpersonal skills in relating with others.
Excellent skills in using Microsoft Office products are required.

Nice To Haves

Advanced college degree with a focus on law, business law, or health administration is strongly preferred.
CHC (Certified in Healthcare Compliance), CIA (Certification in Internal Audit), or equivalent preferred or the ability to obtain necessary certification within 6 months.
Relevant work experience may be substituted for educational requirements.
Knowledge of the Knox-Keene Act and its requirements is strongly preferred.
Knowledge of Risk Adjustment Data Validation (RADV) audits is strongly preferred.

Responsibilities

Plan, design, implement, and refine the Compliance Program.
Develop standards, coordinate compliance training and education.
Conduct or arrange internal and external regulatory audits.
Identify compliance issues and trends, investigate and resolve compliance complaints.
Promote awareness and understanding of ethical and moral practices.
Serve as a primary contact with CMS and the Department of Managed Health Care (DMHC) in California.
Maintain communication with the CMS Regional Office regarding adjudication of Medicare complaints (CTMs), management of corrective action plans (CAPs), implementation of new federal regulations, and approval of marketing materials and plan documents.
Maintain communication with the DMHC Office of Plan Licensing regarding implementation of any new state regulation over commercial products.
Monitor and keep current with Medicare Advantage, California commercial, and National Committee for Quality Assurance (NCQA) contractual and statutory obligations.
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
Develop and launch training and education concerning Aspire’s compliance responsibilities.
Develop and submit state and federal filings/certifications in CMS’ Health Plan Management System (HPMS) and/or the DMHC portal.
Create risk assessments and work plans to ensure compliance program effectiveness.
Monitor key performance indicators (KPIs) and deploy internal audits for the purpose of detecting non-compliance with applicable laws and compliance program requirements.
Manage the development, review, revision and regulatory submission of departmental policies and procedures.
Coordinate Fraud, Waste and Abuse (FWA) investigations with Aspire’s Special Investigations Unit (SIU).
Enforce FWA, Privacy/Security and compliance standards and investigate possible violations.
Initiate HIPAA breach incident reporting to the Office of Civil Right (OCR) and state regulators, if necessary.
Ensure that any detected non-compliance is investigated, a corrective action plan is developed and carried out, and that compliance is achieved and sustained.
Prepare compliance reports to the Board of Directors and Executive Management.
Monitor the effectiveness of the Compliance Program on a regular basis, including a comprehensive review conducted at least annually.
Prepare annual budget for compliance activities.
Prepare operational plans based upon budget projections.
Collaborate with departmental stakeholders to conduct oversight of First Tier, Downstream and Related Entities.
Perform other compliance duties, as assigned.