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Executive Director, Compliance job in Orange | NEWS-Line for Healthcare Professionals

Executive Director, Compliance




Executive Director, Compliance


Job Description


Department(s): Office of Compliance

Reports to: Chief Executive Officer (CEO), with direct access to the Board of Directors and Finance & Audit Committee

FLSA status: Exempt

Salary Grade: U - $209,000 - $313,000


Job Summary


The Executive Director of Compliance shall serve as the Compliance Officer for the organization. The Executive Director oversees and communicates all assigned compliance activities and programs, as well as plans, implements, and monitors the compliance program. The Executive Director of Compliance ensures that CalOptima meets all state and federal regulatory and contractual requirements. The position interacts with CalOptima executive and departmental management, external entities such as health networks, legal counsel, state and federal regulatory agencies, CalOptima's Board of Directors and Finance & Audit Committee, and others as required.


The Executive Director of Compliance is responsible for and oversees a comprehensive and complex program, which includes compliance professionals with expertise and responsibilities for the following areas: Medicare and Medi-Cal regulatory affairs and compliance, audit and oversight for internal and external entities including an extensive provider network at the subcontracted health plan level and direct provider contracts, Fraud, Waste and Abuse (FWA), non-compliance investigations, HIPAA privacy, policies and procedures, organization-wide compliance training, management of the compliance and ethics hotline, and overall development and implementation of the compliance plan for the organization. The Executive Director also oversees the activities of the independent internal audit function, which reports to the Finance & Audit Committee and Board of Directors.


Position Responsibilities:


• Oversees and monitors all aspects of the implementation of the compliance program, including an annual schedule of compliance and audit and oversight activities.

• Oversees the coordination and facilitation of all regulatory audits and monitoring activities for all CalOptima programs (e.g., Medicare Advantage, Medicare-Medicaid Plan, PACE, Medi-Cal, MSSP), audit readiness activities, and remediation of deficiencies resulting from request for corrective action plans (CAPs).

• Ensures that the organization meets all regulatory obligations in a timely and satisfactory manner including, but not be limited to, regulatory reporting requirements, required member and marketing materials, Medicare bids, and all other regulatory filings and deliverables.

• Develops and implements compliance training programs for internal staff and subcontractors such as Code of Conduct, Fraud, Waste, and Abuse, Privacy and Information Security.

• Ensures that the organization is in compliance with all new laws, regulations and directives through tracking, analysis, and communication of state and federal regulatory guidance and contractual requirements with regulators.

• Develops and implements risk assessments and audit plans for internal business areas to include, but not limited to, the claims adjudication process, prior authorizations, pharmacy benefits, credentialing, quality of care, grievance and appeals, customer service, provider directory, etc.

• Develops and implements risk assessments and audit plans for health networks and other first-tier entities for all delegated functions and conducts readiness assessments of all new delegated entities.

• Develops and implements risk assessment and oversight plan for all monitoring activities (e.g., dashboards, file reviews, reports, etc.) of internal business areas and delegated entities.

• Oversees all activities related to the detection, prevention, investigation and reporting of all potential FWA. Act as the liaison between CalOptima and appropriate regulatory agencies (e.g. CMS, DHCS, I-MEDIC, OIG, DOJ) for fraud and abuse issues.

• Oversees all activities related to referrals of potential HIPAA privacy incidents including investigation and reporting of these matters. Provides leadership in coordination with others in the organization for the implementation of all activities related to HIPAA privacy and security.

• Oversees the management of all CalOptima policies and procedures including their development, annual review and revision, maintenance, and approvals (Policy Review Committee, Board of Directors, regulatory agencies, etc.)

• Manages hotline inquiries pertaining to CalOptima, in accordance with the specific processes outlined in CalOptima's hotline policy and procedure, and ensures the organization has a well-publicized and anonymous mechanism for reporting issues of non-compliance and FWA.

• Directs corrective action plans resulting from compliance reviews, risk assessments, etc., and coordinates any necessary policy or procedure changes.

• Works closely with Human Resources when compliance violations occur to ensure consistent, timely and effective disciplinary standards are being met, in accordance with corporate guidance.

• Identifies key stakeholders and subject-matter experts within CalOptima to provide input or assistance for various compliance projects.

• Chairs CalOptima Compliance Committee meetings no less than quarterly and oversees activities of the Audit & Oversight Committee and Policy Review Committee no less than monthly.

• Coordinates with the departments responsible for ensuring that appropriate exclusion monitoring (e.g., OIG, SAM, Medi-Cal S&I, CMS preclusion list) occurs at the required intervals and are acted upon, as necessary for all CalOptima business owners, providers and vendors related to CalOptima.

• Oversees the risk assessment and audit activities of CalOptima's independent auditor.

• Ensures the implementation of the annual Compliance Program Effectiveness (CPE) audit, and related reporting to the Finance & Audit Committee and Board of Directors.

• Provides ongoing reporting on activities to the Chief Executive Officer, the organization's Board of Directors, and Finance & Audit Committee of the Board.

• Other projects and duties as assigned.


Possesses the Ability to:


• Evaluate and analyze regulations, interpret significance, and recommend policies to ensure compliance to applicable regulations.

• Persuade and instill effective cooperation and compliance. Develop rapport and facilitate cooperation, as well as apply sanctions or corrective actions.

• Coordinate effectively with various departments; develop and prepare coordinated responses to ensure uniformity and continuity.

• Apply principles and practices of managed care and quality management.

• Apply internal and external audit practices and activities, including knowledge of regulatory audit protocols.

• Apply principles and practices of effective oversight of the application of contracts.

• Understand federal and state regulatory and other requirements and practices related to Medi-Cal (Medicaid), Title 22, Knox-Keene, Medicare Advantage, Medicare-Medicaid Plan (MMP), and PACE, as well as other governmental and public sector operations and practices.

• Use effective methods and techniques for persuasion and enforcement, compliance and effecting change.

• Use effective methods for managing staff and coordinating the work of interactive groups.

• Utilize in depth knowledge of HIPAA regulations, related federal and state laws and health care accreditation standards.

• Utilize in depth knowledge of FWA regulations, and related federal and state laws.

• Work under the pressure of strict deadlines on multiple projects in a fast-paced environment.

• Communicate clearly and concisely, both verbally and in writing.

• Utilize computer and appropriate software (e.g. Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.


Experience & Education:


• Bachelor's degree or equivalent work experience required.

• 10+ years of experience in a leadership role in a managed care organization required.

• Experience interacting with state and federal regulators required.

• Experience with interpretation and application of state and federal program requirements, regulations and laws required.

• Experience in contracting, monitoring, and enforcing contract provisions and performance management required.


Preferred Qualifications:


• Master's degree in Health Care Administration, Business Administration, Public Administration, Clinical Area, or Law preferred.

• Health Care Compliance certification preferred.

• Medi-Cal and Medicare experience highly preferred.


CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.


If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.


Job Location: Orange, California


To apply, visit https://apptrkr.com/2239939


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