Job Description
Under the direction of the Sr. Director of Compliance and Compliance Supervisor, in support of the Vice President of Compliance, this position will assist in the coordination and implementation of Compliance Program responsibilities and delegated oversight activities with contracted health plans, regulatory entities and vendors. Assist in monitoring PMS business activities, coordinate regulatory changes, support departments and company strategies to ensure compliance with federal, state, and contractual healthcare requirements. Assist in audit preparation and the development of reports/tools to monitor and track implementation and completion of corrective action measures. Supports the compliance team on general standards of conduct, FDR, FWA, OIG, and HIPAA related matters. Cooperates with management, uses sound judgement and critical thinking skills, collaborates with cross-functional teams and performs other duties as assigned. Knowledge of Commercial Insurance, Medicaid, Medicare and Medi/Medi (duals) regulations.
Job Responsibilities/Duties
- Research and interpret complex policies regarding government programs requirements and maintain tracking of all delegation oversight activities from contracted delegated health plans, entities and vendors. Coordinate strategic communications and audits with delegated entities and internal business departments. Manage assigned health plan audits. Independently execute special assignments with general supervision. Monitor oversight and assist in ensuring compliance to regulatory standards and health plan contracts. Apply critical thinking and problem solving skills to all actions.
- Analyze and interpret health plan audits instructions, requests and results, and distribute to operational departments. Use critical judgment to work on developing improvement plans as it pertains to Medicare, Medicaid, Commercial, and Duals program corrective actions. Assist in tracking audit submissions and maintain internal documentation for consistency. Work collaboratively with all departments to follow up on audit items and ensure accuracy of information provided and timely submission, as needed.
- Assist Sr. Director and Supervisor with documenting and analyzing changes across departmental policies when modifications are required due to audit findings and/or regulatory changes. Communicate required changes with business leads and ensure timely compliance with changes. Assist with drafting new policies and updating existing policies as required to ensure regulatory compliance.
- Track and trend areas of compliance and regulatory vulnerability and risk within the organization and assist in developing solutions to enhance processes. Assist Sr. Director and Supervisor in developing and coordinating compliance training materials for the company.
- Assist with research and interpretation of regulatory and contractual requirements and program updates for Medicaid, Medicare and Duals programs. Work with Compliance Programs team to draft and disseminate updates and communications to business units as needed.
- Other duties and related projects as assigned.
Qualifications
Minimum Education: High school diploma or equivalent required, Bachelor’s Degree preferred.
Minimum Experience: Minimum of three (3) years related experience in compliance, regulatory-government programs, preferably with direct experience dealing with interpreting and applying complex Medicaid and Medicare rules and policies in a healthcare administration setting. Preferable experience in IPA within healthcare setting. Strong computer skills, data entry, Word, Excel, Power Point and office equipment. Ability to understand and present information effectively and respond accurately to questions from business departments, outside agencies and vendors, and Management. Strong reasoning, problem-solving, project management and organization skills, with a high level of attention to detail. Excellent verbal/written communication, relationship-building and time management skills. Excellent technical writing skills with the ability to draft policies in a clear, concise manner. Ability to adapt to changing priorities and to manage various projects simultaneously. Work independently on assigned projects. Working knowledge of DHCS, DMHC and CMS requirements is required. Speak, read, and write English proficiently.
Responsibilities
Research and interpret complex policies regarding government programs requirements and maintain tracking of all delegation oversight activities from contracted delegated health plans, entities and vendors. Coordinate strategic communications and FDR audits with delegated entities and internal business departments. Assist Director in monitoring OIG sanction checks. Ability to independently execute special assignments with general supervision. Monitor oversight and assist in ensuring compliance to regulatory standards.|Analyze and interpret health plan audits results and distribute to operational departments. Use critical judgment to work on developing improvement plans as it pertains to Medicare, Medicaid, Commercial, and Duals program corrective actions. Assist in tracking audit submissions and maintains internal documentation for consistency.|Assist Director in developing and coordinating compliance training materials for the company. Work collaboratively with all departments to follow up on audit items and ensure accuracy of information provided and timely submission, as needed.|Assist Director with documenting and analyzing changes across departmental policies when modifications are required due to audit findings and/or regulatory changes. Communicate required changes with business leads and ensure timely compliance with changes. Assist with drafting new policies and updating existing policies as required to ensure regulatory compliance.|Track and trend areas of compliance and regulatory vulnerability and risk within the organization and assist in developing solutions to enhance processes.|Assist with research and interpretation of regulatory and contractual requirements and program updates for Medicaid, Medicare and Duals programs. Work with Compliance Programs team to draft and disseminate updates and communications to business units as needed.
Qualifications
Minimum of three (3) years related experience in compliance, regulatory-government programs, preferably with direct experience dealing with interpreting and applying complex Medicaid and Medicare rules and policies in a healthcare administration setting. Strong computer skills, data entry, Word, Excel, Power Point and office equipment. Ability to understand and present information effectively and respond accurately to questions from business departments, outside agencies and vendors, and Management. Strong reasoning, problem-solving, project management and organization skills, with a high level of attention to detail. Excellent verbal/written communication, relationship-building and time management skills. Excellent technical writing skills with the ability to draft policies in a clear, concise manner. Ability to adapt to changing priorities and to manage various projects simultaneously. Work independently on assigned projects. Working knowledge of DHCS, DMHC and CMS requirements is required. Speak, read, and write English proficiently. Preferable experience in IPA within healthcare setting.High school diploma or GEDBachelors Degree
About Us
With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.
