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Senior Director of Compliance and Risk Management

2 months ago

Oakland, California, United States Kaiser Permanente Full time

Position Overview:

The Director of Compliance in Risk Adjustment is responsible for the strategic oversight and enhancement of a robust risk adjustment compliance framework aimed at preventing legal infractions and promoting ethical conduct in alignment with applicable regulations. This role is pivotal in guiding the risk adjustment compliance operations while ensuring a comprehensive understanding of compliance activities across the organization. The scope of risk adjustment encompasses Medicare Advantage, the Affordable Care Act (ACA), and Medicaid.

Key Responsibilities:

• Act as a subject matter expert in risk adjustment compliance, including coding practices, while supervising both internal and external audit activities related to risk adjustment.

• Monitor adherence to national risk adjustment policies, ensuring that teams remain informed about the latest developments in coding and billing that affect risk adjustment.

• Develop and implement the annual risk adjustment compliance strategy, aligning it with the organization's objectives, and review audit findings to guide compliance reviews and projects based on audit results.

• Foster a culture of continuous learning and professional development within the team, ensuring alignment of resource management with business goals and motivating team members for career advancement.

• Oversee operational activities across various departments by identifying needs, analyzing resources, and translating business strategies into actionable plans while ensuring customer satisfaction and organizational alignment.

• Ensure compliance activities are thoroughly documented and that compliance issues are resolved effectively, while designing strategies for the implementation of regulatory changes.

• Lead compliance reporting initiatives by summarizing compliance data and potential risks, and presenting key findings to senior management and external stakeholders.

• Direct compliance investigations by analyzing data, conducting interviews, and recommending corrective actions for validated issues.

• Manage cross-functional compliance programs by coordinating stakeholder engagement, developing program plans, and overseeing financial and deliverable aspects of the programs.

• Monitor and interpret regulatory changes, assessing their impact on the business and guiding implementation strategies to mitigate compliance risks.

• Oversee risk adjustment initiatives related to Medicare Advantage, ACA, and Medicaid, ensuring alignment between business functions and compliance objectives.

• Stay informed on industry trends and regulatory updates, advising stakeholders on potential risks and necessary policy adjustments.

• Collaborate with various departments to identify risks and enhance processes, ensuring alignment between compliance and operational objectives.

• Prepare and present compliance reports to leadership and relevant committees, ensuring transparency and accountability in compliance efforts.

Qualifications:
  • Minimum of four (4) years in a leadership capacity, with or without direct reports.
  • Bachelor's degree in healthcare administration, law, public health, business, or a related field, along with a minimum of ten (10) years in healthcare compliance, operations, audit, or a related area.
Preferred Qualifications:

• Master’s degree or equivalent experience.

• Extensive experience in Medicare Risk Adjustment and team leadership.

• In-depth knowledge of Medicare Advantage, ACA, and risk adjustment regulations.

• Strong understanding of the Hierarchical Condition Category (HCC) coding model and its implications for risk adjustment.

• Proven leadership and interpersonal skills to effectively engage with diverse teams across the organization.