Director of Compliance

Chapters Health System • Temple Terrace, FL

1d • $106,962 - $167,129 • Hybrid

About The Position

The Director of Compliance is responsible and accountable for the overall implementation, evaluation, and monitoring of the Compliance Program and Plan for CareNu, which will include compliance oversight over all of its subsidiaries. The Director works with various levels of leadership and staff to ensure compliance with state and federal regulations and statutes. Establish a specifically designed compliance program that effectively prevents and/or detects violations of applicable laws and regulations, which will protect the Business from liability of fraudulent or abusive practices. Ensures that the Business understands and complies with applicable laws and regulations pertaining to the Health Care environment. Ensures the Business' accountability across all business lines.

Requirements

• Bachelor's degree in a related field
• Minimum of five (5) years’ prior Medicare Advantage payor / managed care experience preferably in compliance and/or quality management experience with comprehensive knowledge and understanding of CMS, CMMI, NCQA or AAAHC and URAC Credentialing, Delegation and Quality Improvement
• Prior work experience with conducting audits and understanding of auditing methodologies.
• Strong business foundation with proven analytical and problem-solving skills
• Demonstrated skills in fiscal management, utilization of analytical and statistical tools, data analysis, and outcomes management.
• Federal and state regulation knowledge and ability to stay current with updates.
• Able to communicate effectively (written and verbal) in English.
• Excellent skills in management of group dynamics and conflict resolution
• Knowledge of and ability to apply process improvement theory and process mapping.
• Computer knowledgeable and competent with statistical applications and graphics
• Intermittent Driver - Valid driver's license and automobile insurance per Company policy
• Able to travel to off-site locations.
• Able to work with minimal supervision and exercise a high degree of discretion and independent judgment.
• Able to prioritize multiple job responsibilities, exercise critical thinking skills, and effectively handle stress.

Nice To Haves

• Certification by the Healthcare Compliance Association strongly preferred.

Responsibilities

• Directs all activities related to the Corporate Compliance Program, Plan, Code of Conduct and Waste and Abuse Plan across the enterprise while ensuring compliance with governmental requirements.
• Spearheads development and implementation of compliance policies and procedures and training programs across the organization.
• Interprets and disseminates information and compliance matters, including communications from CMS issued through the Health Plan Management System (HPMS).
• Works closely with executive management to create an annual audit plan based on areas of risk, as determined internally and by the Office of Inspector General (OIG); Office of Insurance Regulation and CMS.
• Oversees all activities performed by the Compliance Auditors, including audit tool development, ensuring accuracy and timeliness.
• Directs all billing adjustments, when necessary.
• Maintains an Administrative Adjustment Request Form (AARF) process allowing for tracking and trending causes.
• Directs all responses to all third-party audits.
• Oversees preparation of the Organization’s responses for review by the President, and then, ensures submission of the response on time.
• Prepares all third-party appeals including Administrative Law judge (ALJ) cases.
• Manages compliance hotline process, which includes investigation, follow up, and corrective action, if necessary.
• Conducts external audits of health plan’s delegated entities specific to delegated functions performed in accordance with CMS requirements for those functions.
• Provides input and representation on key compliance initiatives, meetings and committees.
• Stays abreast of industry and compliance trends and recommends and implements changes to internal company processes, as needed.
• Leads educational efforts around compliance, fraud, and abuse within the CMS mandated timeframes.
• Investigates and prepares responses/action plans for any Compliance-related occurrence or anonymous reports.
• Reports to the President and Board on a quarterly basis the status of health plan’s compliance program, including high-risk issues.
• Serves as the HIPAA Privacy Officer; oversees medical record request process.
• Collaborates with the IT Security Officer on security protocols and breaches.
• Actively participates/leads in committees, as assigned.
• Performs other duties as assigned.

Benefits

• Pay Range: $106,962.49 - $167,128.89
• Consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.

What This Job Offers

• Job Type: Full-time
• Career Level: Director