POSITION TITLE: Regulatory Affairs & Compliance Program Manager
DEPARTMENT: Regulatory Affairs and Compliance
FLSA STATUS: Exempt
REPORTS TO: Officer of Compliance & Regulatory Affairs
EVALUATION DATE: 11/2012
Under the general direction of the Officer, Regulatory Affairs and Compliance, the incumbent in this position is responsible for the leadership and implementation of key aspects of the Compliance Program and functions within the Regulatory Affairs and Compliance department. Responsibilities include regulatory oversight and consultation, implementation of new legislation, maintenance and monitoring of memoranda of understanding (MOU) required by the State, compliance oversight, internal auditing, coordination of external auditing, development of education and training programs for staff and providers, and investigating reports of suspected fraudulent or improper business practices.
ESSENTIAL DUTIES & RESPONSIBILITIES:
Leads internal audits of Medical Management, Customer Service and Claims, as well as other departments as necessary. This includes creating or updating any audit tools, performing the audit, preparing results.
Leads the submission of regulatory filings and reports including quarterly grievances, SB 260 and provider network reports to DMHC, MRMIB and CDHCS.
Serves as one of the department’s liaisons with State agencies, including response to State inquiries, audits, report requests, State fair hearings and independent medical review requests.
Oversees delegated provider reporting and auditing.
Conducts fraud and abuse investigations and reporting outcomes as necessary.
Coordinates audits by governmental agencies.
Drafts timely responses to State inquiries, including State Fair Hearings, Independent Medical Review and Consumer Complaints.
Maintains and reports on the Compliance Program.
Trains SFHP staff on aspects of new legislation, contracts, compliance, HIPAA and other regulations.
Coordinates and maintains database of policies and procedures.
Drafts, coordinates and oversees state filings.
Analyzes and coordinates implementation of new regulations and legislation
Creates, maintains and monitors MOUs with community partners, including maintaining a meeting calendar, agendas and communication (1-4 per year depending on the community partner). Coordinate with Provider Relations, UM and Care Support staff as needed for any of the MOUs: CCS, GGRC/ES, CBHS, DAAS; reviews and revises or evergreens each MOU annually; maintains databases related to these MOUs.
INDIVIDUAL CONTRIBUTOR EXPECTATIONS
Takes the necessary steps to ensure he/she understands the SFHP mission and its overarching business goals and objectives.
Acts with integrity, honesty and fairness, remaining mindful of the duty of trust SFHP has to it employees, and to its providers, employers and members.
Accepts and adapts to changes in SFHP policy, practice, procedures quickly and positively and proactively supports his/her colleagues in adapting to changes in the workplace.
Contributes actively and effectively to team discussions, sharing his/her knowledge and expertise willingly and collaboratively.
Takes steps to ensure he/she understands departmental performance competencies metrics. Strives daily to ensure his/her individual performance meets or exceed the performance competencies and metrics. Offers assistance to other members of the team as appropriate in order to help the team meet its overall metrics goals.
Models professional behavior/conduct that remains in concert with the SFHP culture and business values. Leads by example whether in group or individual meetings.
CORE COMPETENCIES / KNOWLEDGE & SKILL REQUIREMENTS
Experience in coordinating and providing support to large complex projects
Excellent oral and written communication skills required
Excellent attention to detail and organizing abilities
Excellent logic, planning and problem-solving skills
Strong knowledge and application of English grammar including composition, editing and proofreading skills
Strong time management and project management skills and multi-tasking abilities
Advanced level proficiency with MS Office applications (Word, Excel, PowerPoint, Access) with expertise with word processing, spreadsheets, graphics and presentation software including the ability to create tables; merge documents; and develop graphics and PowerPoint presentations from notes
Familiar with a variety of general office concepts, practices and procedures.
Possess inquisitive and analytical problem solver with initiative and ability to work independently
EDUCATION, EXPERIENCE & TRAINING REQUIRED
Bachelors Degree in business administration or closely related field.
A minimum of five (5) years experience in health care industry and operations
Specialized knowledge in state programs, regulatory compliance and antifraud activities, required.
Certification in health care compliance preferred.
COMMUNICATION & INTERPERSONAL SKILLS
Written and Verbal:
Ability to clearly present written information and findings.
Ability to clearly and concisely communicate concepts.
Ability to make clear and informative presentations.
Ability to interact well with co-workers and outside contacts.
All Departments within SFHP
External (if applicable):
Department of Public Health
California State Agencies
ESSENTIAL FUNCTIONS—PHYSICAL POSITION REQUIREMENTS; MACHINES AND/OR EQUIPMENT USED
PC proficiency required; MSOffice skills (Outlook, Word, Excel, PowerPoint).
Regularly required to operate standard office equipment (personal computer, photocopy machine, fax machine, etc.)
Ability to work on a computer up to 7 hours a day.
Regularly required to sit for long periods of time, and occasionally stand and walk.
Regularly required to use hands to operate computer and other office equipment.
Close vision required for computer usage.
Occasionally required to stoop, kneel, climb and lift up to 25 pounds.
Standard office environment without unpleasant or hazardous conditions. Work entails typical physical demands involved in office work.
NOTE: This description is not intended to be construed as an exhaustive list of duties, responsibilities or requirements for the position. This position may change or assume additional duties at any time. The employee may be requested to perform different or additional duties as assigned.
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