Compliance and Fraud Prevention Officer

The Compliance and Ethics Officer (“CO”) is expected to serve as a strong and effective leader and promoter of compliance and ethics at Community Health Group (“CHG”). The CO develops, implements, improves, and oversees an effective compliance program to achieve compliance with the Office of the Inspector General’s (“OIG”) Seven Elements of Effective Compliance Program (“Seven Elements”), State and federal law, and industry best practices; identifies functions and business practices requiring compliance activities; designs, develops, implements, and evaluates the Compliance Program and monitors its implementation; and assesses the effectiveness of the Compliance Program and makes necessary changes to achieve the goals of model compliance in addition to preventing illegal, unethical, or improper conduct pursuant to 42 C.F.R. §§422.503(b)(4)(vi)(B), 423.504(b)(4)(vi)(B), and other applicable authority. The CO reports directly to the Associate Chief Executive Officer (“ACEO”) with a dotted line to the Board of Directors. This position reports compliance issues directly to the Chief Executive Officer (“CEO”), the ACEO, and/or the Board of Directors, as appropriate. This is a full-time position and will be primarily responsible for oversight of the compliance requirements of Medi-Cal, Cal Medi-Connect Part C and D programs, and Knox-Keene licensure. The CO is also responsible for overseeing the Health Insurance Portability and Accountability Act privacy requirements (in partnership with the information security requirements as overseen by the Chief Information Officer) and First Tier, Downstream or Related Entities (“FDR”) compliance programs, pursuant to 42 C.F.R. §§ 422.503(b)(4)(vi)(F), 423.504(b)(4)(vi)(F), and other applicable authority.

COMPLIANCE WITH REQUIREMENTS

Comply with all applicable legal and compliance requirements, including but not limited to federal and State laws and regulations; privacy, confidentiality, and information security mandates; and CHG policies and procedures.

POSITION DUTIES

• Develop and direct programs to meet all applicable legal, regulatory, contractual, and, as applicable, accreditation requirements.
• Develop, implement, execute, and improve the Compliance Program in accordance with industry standards, best practices, and in compliance with the OIG’s Seven Elements.
• Chair Compliance Committee and assess and improve its effectiveness.
• Recommend and maintain dashboards and other efficient and effective reports for the Compliance Committee, leadership, and Board of Directors.
• Keep ACEO, CEO, and Board of Directors informed of compliance issues on a timely basis, including providing effective monthly CEO and Board reports.
• Work closely with all departments necessary to ensure that the operational processes, programs, and services are accomplished in a compliant manner in accordance with CHG policies and procedures and in compliance with applicable State and federal regulations including but not limited to Centers for Medicare and Medicaid Services (“CMS”), Department of Health Care Services (“DHCS”), Department of Managed Health Care (“DMHC”), Medicare Part D and Medicare Advantage Plans, HIPAA and other privacy requirements, and other applicable authority. Oversee reporting of implementation of operational compliance changes.
• Conduct at least annual or other periodic risk assessments and develop strategies and make recommendations for risk management.
• Develop, improve, and implement Fraud Waste and Abuse Prevention and Detection Program (“FWA Program”).
• Coordinate and oversee the Internal Auditing and Monitoring Program (“IAM Program”) including internal monitoring and reporting, audits, investigations, and corrective action plans (“CAPs”).
• Develop and oversee an effective FDR, third party, and delegation oversight program (“FDR Oversight Program”), in partnership with applicable internal stakeholders.
• Develop, improve, and implement Privacy Compliance Program.
• Oversee the Regulatory Affairs Program.
• Perform strategic planning to assure the Compliance Program and Department aligns with CHG’s strategic objectives and compliance requirements; execute and evaluate progress toward goals.
• Develop, implement, execute, and improve strategy and programs for effective internal and external compliance training, awareness, and communication.
• Assure the development of, adherence to, and maintenance of policies and procedures throughout the organization.
• Participate in enterprise-wide business continuity planning and preparation.
• Maintain a strong working knowledge of all applicable legal, regulatory, contractual, and accreditation requirements. Update job knowledge by participating in educational opportunities and reading professional publications.
• Discharge other duties as may be required in the course of business or as may be assigned by the ACEO, CEO, or Board of Directors.

ADMINISTRATION AND MANAGEMENT

• Develop and maintain short- and long-term objectives, compliance standards and operational policies and procedures.
• Oversee and manage Regulatory Affairs Manager, Senior Compliance Consultant, and Compliance Analysts.
• Develop annual performance targets and evaluate Compliance Department staff.
• Oversee the recruitment and hiring of Department staff.
• Identify necessary resources, recommend budget, staffing, and other resource allocations to achieve the aims of the Department. Track and adhere to annual approved budget. Budget, recommend, assess, and oversee external consultants, vendors, and contractors.

QUALIFICATIONS

Education

• Master’s degree in compliance, health policy, health administration, or other related discipline. Managed health care management experience may be considered in lieu of graduate academic training.
• Certification in Healthcare Compliance (“CHC”) from the Health Care Compliance Association is required to be obtained within one (1) year of hire.

Experience/Skills

• Minimum of 8 – 10 years health care administration and compliance experience with CMS, DMHC and DHCS expertise.
• Minimum 8 – 10 years progressively responsible management experience in managed care compliance, preferably in California.
• Expert level understanding and experience with HIPAA, Knox-Keene Act, Medi-Cal, and Medicare requirements.
• Understanding of NCQA, State/Federal legislative and regulatory processes, CHG operations, and the relationships between departments and functional areas.
• Prefer prior experience with CMS, DMHC, and/or DHCS.
• Excellent written and verbal communication skills.
• Demonstrated leadership and executive presence skills.
• Ability to effectively present information and respond to questions from Board, senior leadership regulators, staff, and other stakeholders.
• Ability to use independent judgment and to manage and impart confidential information.
• Ability to maintain confidentiality and comply with applicable privacy and confidentiality requirements.
• Intermediate to advanced level proficiency with MS Office applications (Word, Excel, PowerPoint, Access), expertise with graphics and presentation software.

Physical Requirements

• Prolonged periods of sitting.
• Frequent traveling, including driving within the County of San Diego.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.