PRINCIPAL RESPONSIBILITIES:
Under the direction of the Chief Compliance & Privacy Office (CCO/CPO), this position leads the implementation and operations of the Health Plans Compliance Program, including the HIPAA/Privacy and Anti-Fraud programs, in accordance with the Department of Managed Health Care (DMHC) and Department of Health Care Service (DHCS) laws and regulations. This position works closely with management and employees to facilitate compliance with applicable federal and state regulatory requirements
Principal responsibilities include:

Develops and implements the annual Compliance Program, Code of Conduct, and department objectives; Develops, implements, and ensures compliance with Plans Fraud Prevention Program and serves as the Plan's Fraud Prevention Officer. Regularly attends and participates in The Department of Health Care Services (DHCS) Quarterly Fraud & Program Integrity meetings; Reviews and analyzes regulations to determine the impact on plan operations and identifies the need for new or revised policies, procedures, plan documents; Establishes an annual internal audit work plan for ongoing review of operations to ensure regulatory compliance standards are met and any issues found are corrected; Develops the annual Anti-Fraud Plan, oversees the fraud, waste, and abuse policies and procedures, investigations, and reporting to the State regulatory agencies; Supports the maintenance of the HIPAA/Privacy program, policies and procedures, audit and oversight activities, investigations, and reporting to the State regulatory agencies; Reports investigations routinely to the CCO/CPO and quarterly to the Compliance & Delegation Oversight Committees; Oversees the delegation oversight program for auditing, reporting, and monitoring delegation activities; develop and implement the audit schedule and corrective action plan process; participating in delegation joint operational meetings; Designs compliance training and materials for the Compliance department and the overall organization; Oversees communications and reporting with the regulatory agencies such as DMHC filing submissions, regulatory reporting and the ad-hoc requests; Develops routine updates of the Compliance program to the CCO/CPO and senior leadership; Participates in the DMHC and DHCS regulatory meetings and maintains relationships with the regulatory agencies; Works collaboratively with departments to ensure operations are within compliance and participates as a member of internal sub-committees; Reviews and develops policies and procedures from a regulatory compliance perspective and maintains annual review and management of policies and procedures; Updates key management staff of new or updated regulatory changes/developments of new managed care legislative initiatives on functional areas; Monitors the performance of the Compliance Program and relates activities on a continuing basis, taking appropriate steps to improve its effectiveness. Prepare and submit routine regulatory reports and analysis to include, but not limited to, Department of Health Care Services (DHCS); Department of Managed Health Care (DMHC); the California Department of Public Health (CDPH); Centers for Medicare and Medicaid Services (CMS)
ESSENTIAL FUNCTIONS OF THE JOB
Directs the Health Plans day-to-day Compliance program operations and activities; Ensures key operational departments understand and adhere to state and federal regulatory and contractual compliance standards; Analyzes regulations, assesses risks, and coordinates the implementation of changes with internal department teams to meet compliance; Leads external and internal auditing activities for the Health Plan; Coordinates all incidents and violations reported to the Compliance and Privacy Department are investigated; collaborates with other departments for the investigation and resolution process; Oversees the delegation oversight program for monitoring delegation reporting and annual auditing activities. Oversees the daily operations of the Special Investigations Unit. Effective public speaking, written and verbal communication skills. Ability to research and interpret local, state and federal regulations. Provide leadership and direct supervision to staff. Recruit, hire, train, and retain qualified staff.
PHYSICAL REQUIREMENTS

Constant and close visual work at desk or computer; Constant data entry using keyboard and/or mouse; Constant sitting and working at desk; Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person; Frequent lifting of folders and various objects weighing between 0 and 30 lbs; Frequent walking and standing; Occasional driving of an automobile; Occasional travel between offices for meetings; and Possible travel by aircraft.
Number of Employees Supervised: 10-20
MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

5+ years experience in a managed care healthcare setting with experience in Compliance, HIPAA/Privacy, FWA and/or Regulatory Affairs operations.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

Bachelors degree in a related field required; Minimum of 3 - 5 years management in health care operations required Certificate of Healthcare Compliance (CHC) preferred

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

Expert knowledge of state regulatory requirements under Department of Managed Health Care and Department of Health Care Services; Expert knowledge of privacy laws applicable to the health plans; Strong analytical skills, including the ability to interpret and determine the impact of complex laws, regulations and other documents; Knowledge of regulatory external audits, internal auditing and effective implementation, control and monitoring processes; Commitment to and ability to facilitate and atmosphere of collaboration and team work; Strong interpersonal skills with the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside the Health Plan; The ability to independently achieve objectives and resolve issues under ambiguous circumstances is a must; Strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals; Strong decision-making, organizational, planning and problem solving skills, and communication skills are a needed to effectively interact with staff, team members and others in a professional and tactful manner; Have the ability to lead, and to provide training and guidance to the other members of the department; Ability to supervise staff in a manner that maximizes employee performance and business results; Ability to handle confidential information with appropriate discretion; Strong presentation skills with the ability to tailor presentations to a specific audience, and address and interact with large groups.
SALARY RANGE $185,153.97-$277,730.96 ANNUALLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.