Mgr Medicare Compliance
- Tech Way
Shift Start Time:8 AM
Shift End Time:5 AM
Additional Shift Information:
Weekend Requirements:No Weekends
What You Will Do
Responsible for the development, implementation and maintenance of an effective compliance program in accordance with state and federal statutory and regulatory requirements and Sharp Health Plan policies and procedures. Responsible for providing effective leadership for Sharp Health Plan in the areas of: commercial and government program health plan compliance; privacy; fraud, waste and abuse; government contract compliance; and delegation oversight. Responsible for plan-wide audit activities, including audits of Sharp Health Plan's internal business units and first tier, downstream and related entities (FDRs). Directs follow-up assessment of newly implemented legislative and regulatory requirements to ensure compliance. Participates in the development of risk assessment tools and in conducting risk assessments for business units and FDRs, and develops a comprehensive audit plan tailored to address the relative risks presented by each business unit and FDR. Develops and maintains compliance-training programs. Develops and maintains subject matter expertise on legislative, regulatory and contractual issues affecting commercial and Medicare health plans in California. Monitors industry best practices and makes recommendations for organizational policy and procedure change that will result in compliance. Cultivates positive relationships with regulators, including, but not limited to, the Center for Medicare & Medicaid Services (CMS) and the California Department of Managed Health Care (DMHC). Interacts effectively with various internal and external departments and leaders to provide guidance, information and assistance. Reports on compliance activities to the Director of Compliance and Regulatory Affairs and the Chief Compliance Officer. Promotes the satisfaction, development and productivity of department staff. Participates as a part of, and in support of, a management team that works collaboratively to ensure the success of Sharp Health Plan's goals, objectives, and strategic initiatives.
- Bachelor's Degree Business, law, health care administration or related field.
- 3 Years compliance experience within the health care industry.
- 3 Years position requiring high levels of cooperation and collaboration.
- Experience in a leadership role, ideally leading and implementing a comprehensive compliance program.
- Experience conducting research, thorough analysis, interpretation of findings and preparing concise, accurate reports.
- Master's Degree Business, law, health care administration or related field.
- Other : Juris Doctor
- Experience with legislative and regulatory issues affecting commercial health care service plans in California.
- __Leads compliance strategy, programs and goals.__
* Develops and recommends programs and policies that position Sharp Health Plan for compliance consistent with mission, values, and vision.
* Leads integration of policies and programs, internally and with Sharp Health Plan's medical group and vendor communities. Recommends operational changes/ enhancements to ensure regulatory compliance aligned with strategic direction.
* Works with Sharp Health Plan and system leadership as appropriate to coordinate and optimize compliance activities. Works with leaders to ensure internal controls are sufficient to ensure compliance.
* Completes annual risk assessments to identify compliance priorities.
* Ensures that regulatory compliance activities are consistent with accreditation standards.
* Ensures compliance committees meet regularly.
- __Ensures effective communication and training of compliance requirements, risks, and performance.__
* Communicates the importance of compliance and the compliance program to senior management, the compliance committee, and health plan staff.
* Provides adequate information to operational leaders to ensure that they and their employees have the requisite information and knowledge of regulatory issues and requirements to carry out their responsibilities in a compliant manner.
* Provides multiple channels for staff and leaders to report compliance concerns and potential privacy breaches.
* Oversees the development of routine and ad hoc training programs addressing compliance.
* Develops and maintains effective communication with all levels of management as well as legislators, regulators, lobbyists, trade groups and other relevant external parties.
* Reports to the Director of Compliance and Regulatory Affairs and executive management on status of implementations and internal assessments. Develops periodic reports and an annual evaluation of the compliance program.
- __Directs internal and external monitoring and oversight programs.__
* Develops and implements monitoring and oversight programs to ensure Sharp Health Plan’s compliance with legal and regulatory requirements.
* Works collaboratively with other leaders to develop sufficient controls capable of preventing and detecting significant patterns of non-compliant conduct.
* Conducts compliance reviews of Sharp Health Plan activities through internal audits, mock audits, reporting, breach investigation and other methods.
* Maintains delegation oversight program designed to meet regulator expectations and requirements, and ensures delegates are performing functions in a compliant manner. Consults with business owners to ensure delegation oversight expectations are consistent with industry standards.
* Leads interdepartmental fraud, waste and abuse committee, and ensures appropriate prevention, detection, investigation and reporting.
* Manages the coordination of remote and on-site non-financial external audits. Ensures deliverables are complete, accurate and timely for external audits. Advises business owners on audit best practices.
* Prepares accurate and thorough reports that identify potential deficiencies, risks and issues and, as appropriate, recommends corrective actions and conducts reassessments of performance once corrective actions have been implemented.
- __Manages government contracting process and ensures compliance with key provisions and performance guarantees.__
* Reviews and evaluates non-financial provisions of new and amended government contracts, and ensures executive review and approval.
* In partnership with the applicable account management leader, ensures that business owners are aware of contract requirements.
* Develops and implements oversight program to assess compliance with government contracts.
- __Acts as a liaison with Sharp HealthCare legal and compliance resources and outside legal counsel, as needed.__
* As appropriate, consults and collaborates with legal and compliance resources, including, but not limited to:
* Arbitration and litigation cases
* Legal interpretation
* Risk management
* Potential privacy breaches
* Fraud, waste and abuse investigations
* Consults with Human Resources as needed regarding identified instances of non-compliance and the need for further investigation. Refers proposed corrective action to the applicable Sharp Health Plan leader.
* Supports the Director of Compliance and Regulatory Affairs in sharing information about Sharp Health Plan compliance activities and risks with Sharp HealthCare Compliance leaders and staff. Participates in identifying opportunities for collaboration and best-practice sharing.
- __Completes hiring, training, and supervision of department staff.__
* Hires, supervises, and coaches staff to ensure efficient and effective operations.
* Ensures compliance with human resources policies and departmental protocols.
* Assesses staff skill levels and training needs, and provides feedback on performance. Develops curriculum for new and existing staff.
* Maintains high level of teamwork and staff morale.
- __Manages department workflow and identifies opportunities for improvement.__
* Anticipates resource needs and organizes workflow to meet internal and external customer demands, expectations, timelines, and deadlines.
* Identifies and resolves operational problems and inefficiencies to ensure continued high-quality service, achieve required results, and promote staff morale and job satisfaction.
* Identifies and develops plans to address opportunities to improve Sharp Health Plan and department performance, and evaluates the success of such projects. Ensures departmental efficiency and effectiveness through continuous quality improvement initiatives.
- __Reports regularly on departmental activities, risks, results, key indicators and trends.__
* Prepares scheduled and ad hoc reports and analyses as needed to document Sharp Health Plan compliance activities and department performance.
* Identifies and documents risks, obstacles and priorities.
* Develops action plans and prepares regular updates.
* Presents reports to Director of Compliance and Regulatory Affairs and, as appropriate, other Sharp Health Plan leaders.
- __Provides internal and external customer service.__
* Consistent with the Sharp HealthCare leader behavior standards, provides prompt, accurate and excellent services to internal and external customers.
* Develops solid professional working relationships with internal departments and units and, as required, vendors, providers, employers, brokers and/or other customers.
* Demonstrates collaborative approach to problem-solving. Negotiates effectively.
Knowledge, Skills, and Abilities
- Strong leadership and management skills with ability to supervise, motivate and coach staff.
- High level of integrity; ability to exercise sound judgement and maintain confidentiality.
- Excellent diplomacy skills to resolve issues effectively.
- Strong analytical skills and attention to detail.
- Readily adaptable to the changing needs of the business and demonstrated ability to effectively manage multiple priorities.
- Tolerance for ambiguity.
- Exceptional planning, communication (both verbal and written), time management, organizational and follow-through skills with a strong sense of urgency in a fast-paced environment.
- Demonstrated ability to prepare and present information in a clear and concise manner and formulate recommendations.
- Ability to represent Sharp Health Plan effectively internally and externally in dealings with peers, executives, legislators, regulators, consultants, vendors or other parties.
- Working knowledge of and the ability to operate applicable computer software efficiently, including a working knowledge of computer applications such as electronic mail software and Microsoft Office Suite.
- Ability to use a keyboard with moderate speed and a high level of accuracy.
- Knowledge of state and federal laws and regulations governing health plans, including the Knox-Keene Act, HIPAA, ERISA, COBRA, Affordable Care Act, etc.-Preferred
- Thorough understanding of health care delivery models, health care benefits and health plan operations.-Preferred
- Knowledge of the National Committee for Quality Assurance (NCQA) accreditation standards related to delegation oversight, privacy, and other applicable areas.-Preferred
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class
Master's Degree; Other; Bachelor's Degree
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"After nearly 10 years of working here, it's still one of the hardest jobs I've ever loved. If you find a niche here, you'll be working with some of the smartest in the industry. This is where they'll respect you for thinking outside the box and kindness matters. They expect consistency and hard work, but pay you well to do it."
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