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Compliance Specialist - Monitoring/Oversight

Job ID 86022 Date posted 02/09/2018
  • Facility: Sharp HealthPlan
  • City: San Diego
  • Department: Operations
  • Category: Business Operations Jobs
  • Job Status: Full-Time
  • Shift: Day Job
  • FTE: 1.0
  • Shift Start: 8 AM
  • Shift End Time: 5 PM


This position is located in Kearny Mesa, San Diego County



8:00am-5:00pm, weekends as needed


Required Skills and Qualifications

  • Five (5) years experience in position requiring high levels of cooperation, collaboration, analysis, troubleshooting, project management and problem resolution
  • Knowledge of state and federal regulations including Knox Keene Act, California Code of Regulations, especially Title 28
  • Knowledge of Health plan operations
  • Ability to function independently, make sound decisions based upon thorough investigation of available information, manage deadlines and priorities, and manage a variety of activities simultaneously
  • Effective interpersonal skills; excellent oral and written communication skills
  • Comfortable interacting with executive level positions both internally and externally


Preferred Skills and Qualifications

  • Undergraduate degree in business, law or related field
  • Familiarity with Medicare and health insurance, and Medicare Advantage plans
  • Auditing experience


The Compliance Specialist is responsible for serving as Sharp Health Plan’s primary resource for regulatory requirements related to the Compliance Verification and Delegation Oversight programs. Maintains the compliance verification program and conducts ongoing internal oversight audits to maintain Plan compliance with state and federal regulatory requirements and government contract provisions. Coordinates the delegation oversight program for Sharp Health Plan, including review of services provided by contracted medical groups and ancillary providers. This position is also responsible for completing assigned projects related to Sharp Health Plan's compliance with state and federal laws and regulations related to health care service plans. Projects may include but are not limited to implementation plans for new legislation, regulatory analysis of contractual agreements, and assessment of Plan compliance with specific regulations (e.g., evidence of coverage, provider contracts, member notices).

Sharp Health Plan is San Diego’s only locally-based commercial health plan. It operates as a not-for-profit health plan, committed to delivering the best health care for the best value.  With an NCQA Accreditation status of Excellent and a member satisfaction rating at the 90th percentile*, Sharp Health Plan serves a growing number of individuals and companies, large and small, in San Diego and southern Riverside counties.  The Legislative and Regulatory Affairs Department is responsible for ensuring Sharp Health Plan's compliance with state and federal laws and regulations.

* Compared to all publicly reporting health plans nationally, Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey, 2016. 

Essential Physical Requirements may include:

Incumbent spends approximately 4-6 hours per day sitting at desk, entering data on computer terminal and talking on telephone.  Incumbent spends approximately 1-2 hours per day walking between Plan departments.  Must be able to hear and speak clearly by telephone. Must be able to meet frequent deadlines and tight schedules.  Must be able to lift 5 – 20 pounds, primarily paper reports and filing.  Ability to travel between Sharp Health Plan, other Sharp HealthCare facilities, customer locations and community resources.  Must provide own transportation.

Additional physical requirements of position may be discussed during interview.

Sharp HealthCare is proud to be an Equal Opportunity/Affirmative Action Employer.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, gender identity, transgender status, sexual orientation, protected veteran status or any other protected class.

Keywords: Compliance, Oversight, Managed Care, Audit

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