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Medicare Compliance Officer

4 months ago

Rockledge, United States Health First Full time
Job Description

POSITION SUMMARY

Ensuring the Health First Health Plans (HFHP) Compliance Department functions as an independent and objective body that reviews and evaluates Integrity issues and concerns. In coordination with Health First Inc. this individual will lead the team to educate the Health Plan associates and ensure compliance with all State and Federal regulations. This position reports to the HFHP President, Health First Chief Integrity Officer, and HFHP Board of Directors, to ensure that all associates, Board members, and related parties understand and comply with rules and regulations, follow company policies and procedures, and behave in a manner that meets the company's Code of Ethics and Business Conduct.

PRIMARY ACCOUNTABILITIES

  1. Establish short and long-range objectives in support of the Health First Chief Integrity Officer to include gaining approval of and executing an annual monitoring and auditing work plan based on risk to the organization and managing the elements of an Effective Compliance Program.
  2. Monitor and research healthcare regulatory and business requirements from both state and federal regulatory sources.
  3. Ensure adherence to state and federal reporting requirements.
  4. Develop and oversee an effective process for communicating regulatory information in a clear and concise manner and implementing solutions to support internal and external operational and compliance activities.
  5. Work with HFHP and IDN leaders (as appropriate) to address top concerns, areas of risk, regulatory changes, and their impact.
  6. Facilitate the timely submission of the annual Medicare bid to CMS and form and rate filings with the OIR. Work with Actuary, CMS and the OIR to gain approval of the filings as appropriate.
  7. Prepare and participate in the HFHP Operational and Compliance Committee Meetings which include reports and recommendations supporting the Regulatory and Medicare Compliance Program.
  8. Establish and maintain key relationships with Operations, Legal Counsel, Privacy, Special Investigations Unit (SIU), and the Corporate Integrity Teams.
  9. Oversee the coordination of internal and external audits and site visits as it relates to Operations, the OIR, ACHA, CMS and other regulatory and governmental agencies.
  10. Responsible for ensuring development and adherence of mandatory training and education requirements for associates and First Tier and Delegated Entities.
  11. Provide support for the development and adherence of the Health First Code of Ethics and Business Conduct document.
  12. Oversee investigations for any incoming compliance complaints of potential noncompliance. Work with SIU in regard to potential Fraud, Waste and Abuse.
  13. Facilitate the annual risk assessment process and the development of the annual Work Plan.
  14. Responsible for developing and maintaining policies and procedures for the HFHP Integrity department and Compliance Program.
  15. Continuously improve upon staff education, communication/support while maintaining a positive work environment for associates.
  16. Serve as primary point of communication with regulatory agencies to build relationships, instill confidence, mitigate risk and keep executive HFHP leadership informed.


LEADER ACCOUNTABILITIES

  1. Define and communicate a clear, compelling vision for the team that effectively ties into the mission and vision of Health First and inspire the team to achieve that vision.
  2. Provide leadership, motivation, coaching, feedback, and support to foster and strengthen growth and development of an effective, high performing team.
  3. Lead change through effective communication, explaining the connection and value to the organization, creating stronger buy-in and urgency, while understanding impact to the team to obtain commitment.
  4. Demonstrate openness to hearing diverse ideas and thoughts; create a sense of inclusivity; and encourage collaboration across teams to help break down silos to meet the team's and organization's goals.
  5. Recruit, select, grow, and retain highly engaged, high performing diverse and inclusive associates.
  6. Display strong strategic and financial acumen in areas of responsibility in alignment with the organization's strategic objectives.


Qualifications:

MINIMUM QUALIFICATIONS

Education: Bachelor's degree in a clinical or business field.
Work Experience: Five years of health plans Medicare Advantage & Individual & Family plans, regulatory or compliance experience. Experience in a health plan environment.
Licensure: None
Certification: None
Skills/Knowledge/Abilities:

  • Ability to analyze and communicate regulatory requirements
  • Experience managing and leading complex projects
  • Excellent oral, written and presentation skills
  • Excellent problem-solving skills
  • Working knowledge of Microsoft Office and database applications
  • Planning and organizational skills


PREFERRED QUALIFICATIONS

Education: Master's degree in a clinical or business field or Juris Masters.
Work Experience: Experience in health plan regulatory or health plan compliance program operations specializing in Medicare Advantage
Licensure: None
Certification: Advanced health care compliance / certification
Skills/Knowledge/Abilities:

  • Implementing and maintaining a successful Health Plan Compliance and Regulatory Program.


PHYSICAL REQUIREMENTS

  • The majority of time involves sitting or standing; occasional walking, bending, and stooping.
  • Long periods of computer time or at workstation.
  • Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
  • May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
  • Communicating with others to exchange information.
  • Visual acuity and hand-eye coordination to perform tasks.
  • Workspace may vary from open to confined, onsite, or remote.
  • May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.