Manager, Enterprise Compliance

Description

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.  

Who Are We? ✨ 

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. 

Why Join Us? 🏆

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. 

Job Summary

This role implements and monitors company policies and procedures to ensure compliance with all applicable statutes, regulations, rules, and policies as outlined below. The Manager is responsible for providing on-site and virtual compliance education in line with enterprise objectives, including educating employees on Clever Care’s Code of Conduct, compliance and privacy policies, compliance work plan, and privacy work plan. The Manager tracks laws and regulations that might affect the organization’s policies and procedures and works with other members of the company’s ethics and compliance team to design policies and training as appropriate.  The Manager investigates reports of alleged violations of the company’s policies, federal, state, and local laws. The Manager gathers information and prepares reports, advises, and issues guidance on privacy and compliance matters. Under the direction of the Compliance Officer, the Manager provides an essential compliance presence to ensure a consistent approach to all matters related to ethics and compliance. May manage the Internal Auditor.

Functions & Job Responsibilities

• Regulatory Compliance, Reporting, and Audits: Track laws and regulations that might affect the organization’s policies and procedures and work with other members of the company’s ethics and compliance team to design policies and training as appropriate. This role will be interfacing with CMS and DMHC on regulatory reporting, drafting regulatory submissions for both agencies, responding to comment letters, preparing filings, and internally coordinating regulatory audit demands. Serve as a backup contact for the CMS and other regulatory agencies to the Audit & Compliance Officer. Responsible for official responses regarding issues, complaints and enforcement actions. Respond to government investigations and queries as the principal point of contact. Serves as a lead on regulatory audits that utilize internal data such as the annual Data Validation audit, annual Part C Reporting, and annual CMS Mock-Audits and all unanticipated regulatory audits.

• Privacy: Develop a HIPAA Privacy Program to assess impact, apply the four-factor test to incidents, establish a protocol to support impacted members, and track notice requirements to state and federal agencies, members, and the media. Maintain a system to house all Privacy incidents and breaches.
• Marketing: Build out and maintain a program to review all Marketing and Sales material, including advertisements and annual notices, submit to CMS for review and approval, track retired material, assign material IDs, and be the accountable party across the organization to Compliance Marketing.
• Internal Audit and Monitoring : Maintain and manage a program to oversee adherence to regulatory requirements by auditing and monitoring internal operations and controls. Create a monitoring dashboard and final audit reports to report to leadership on overall performance, and track deficiencies and corrective action plans to ensure the organization maintains a state of compliance.
• Internal Investigations and Conflicts of Interest: Identify risk proactively, direct audits and corrective actions, investigate reported non-compliance and Code of Conduct violations, and ensure non-compliance issues are promptly investigated and resolved. Manage and minimize risk for conflicts of interest.
• Executive Reports: Prepare executive reports for the respective Audit and Compliance Committees.
• Other Functions as Needed.

Other:

• Maintain an up-to-date knowledge of audit & compliance requirements.
• Collaborate with other departments on compliance risk, issues, audits and corrective actions.
• Apply Internal Audit standards to the application of the Medicare Advantage requirements and internal operational reviews
• Consult with General Counsel/lawyer, as needed, to identify and resolve legal issues and concerns.
• Perform functions according to established policies and procedures, regulatory requirements, and applicable professional standards.
• Provide customers, internal and external, with professional service and demonstrate core and leadership behaviors.
• Additional duties, as assigned.

Leadership Expectations

By way of leadership approach, mobilize others to create extraordinary results, and unite people to turn challenges into successes by championing the following:

1. Model the Way:

• Clarify values by finding your voice and affirming shared values
• Set the example by aligning actions with shared values

2. Inspire a Shared Vision

• Envision the future by imagining exciting and ennobling possibilities
• Enlist others in a common vision by appealing to shared aspirations

3. Challenge the Process

• Search for opportunities by seizing the initiative and looking outward for innovative ways to improve
• Experiment and take risks by consistently generating small wins and learning from experience

4. Enable Others to Act

• Foster collaboration by building trust and facilitating relationships
• Strengthen others by increasing self-determination and developing competence

5. Encourage the Heart

• Recognize contributions by showing appreciation for individual excellence
• Celebrate the values and victories by creating a spirit of community
   

Qualifications

Required Qualifications

• Bachelor's degree is required.
• Minimum 5 years of Medicare Audit or Compliance experience.
• Minimum of 3 years managing teams and compliance programs
• Advance knowledge of Medicare Advantage CMS and California DMHC regulations.
• Advance knowledge of HIPAA regulations is required.
• Familiarity with Institute of Internal Auditors standards

Skills:

• Strong organizational skills: Ability to multitask and problem solving.
• Experienced in interfacing with national and regional CMS offices.
• Presentation skills for training large and small groups.
• Excellent communication skills.
• Analytical and critical thinking skills are required.
• Exhibit initiative and ability to assume responsibility and maintain confidentiality.

Wage Range: $90,000.00/yr - $97,640.00/yr

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required  
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

Salary : $90,000 - $97,640