Senior Compliance Specialist

Summary:

This position is responsible for support of the administration and oversight of Jefferson Health Plans Compliance Program. The Sr. Compliance Specialist will support the Compliance management team by ensuring ongoing compliance with contractual and regulatory obligations and State and Federal requirements related to health insurance and managed care. In close collaboration with all business units, this position will demonstrate leadership and provide support and compliance strategy throughout JHP in the organization’s efforts to achieve key objectives, maintain and improve compliance. The Sr. Compliance Specialist will play an integral role in researching and tracking regulatory issues and maintaining full regulatory compliance. This role is responsible for supporting a diverse range of compliance-related responsibilities associated with HPP’s Medicare Advantage/Prescription Drug Program, Pennsylvania Medicaid, Pennsylvania CHIP lines of business.

Primary Responsibilities:

• Serve as primary support to Compliance Management with oversight and execution of various compliance related functions
• Provide limited supervisory and mentoring to Compliance Specialists with similar downstream responsibilities as deemed necessary by departmental management
• Assist in the provisional oversight of the Company’s Compliance Program
• Act as liaison to JHP internal business units for day-to-day assistance with regulatory/ operational compliance issues and concerns, including requests for information and/or clarification
• Receive, coordinate follow-up and respond to all requests for information and/or clarification received from regulatory entities or internal business units/departments
• Once documentation is ready for submission to a regulatory entity, the Sr. Compliance Specialist will review prior to the submission
• May be required to assist management in reviewing, clarifying and disseminating pending and newly enacted regulations, sub-regulatory guidance and state contractual revisions to appropriate JHP staff
• May be required to serve as a point of contact for all internal departments for management of CMS/ DHS communications including, but no limited to: HPMS issued guidance, Medical Assistance Bulletins, Managed Care Operations Memos, System Notices, relevant regulatory and sub-regulatory guidance, and HealthChoices/ CHIP contractual revisions
• Assist in workgroups for implementation of Medicare, HealthChoices, and CHIP requirements
• Assist with development of internal policies and procedures
• Ensure the timely and accurate review, routing and tracking of regulatory submissions
• Support the Compliance department with data reporting requirements as needed
• Lead and/ or provide support for both internal and external audits when necessary
• Review audit results when appropriate in order to enhance Compliance monitoring activities
• Lead and/ or provide support for compliance monitoring activities when necessary
• Assist in the investigation of both actual and suspected compliance risks
• Maintain accurate and timely reporting/project mechanisms that afford management with easily accessible information regarding the status of compliance issues
• Develop "job aids" conveying compliance requirements for use by the Compliance Department
• Develop and maintain collaborative relationships with internal and external customers
• Serve as a point-of-contact for questions and complaints from internal and external customers regarding business practices, Code of Business Conduct issues and corporate policies, including issues of a sensitive or confidential nature
• Investigate and analyze facts and circumstances alleged in compliance complaints and inquiries, and provides prompt, concise answers to inquiries, complaints, and/or concerns regarding the Code of Business Conduct, corporate policies, and the Compliance Program
• Develop, coordinate and maintain any applicable risk assessments
• Offer creative input on communication and organizational strategies to ensure compliance with key regulatory or operational deliverables as they relate to JHP business
• Analyze regulatory entity inquiries and establish internal deadlines to ensure responses are timely and appropriate. Consult with all relevant individuals/entities in seeking clarification of inquiry/ issue resolution, including follow-up as appropriate
• Continually communicate with various internal management teams to ensure compliance with contractual requirements to assist in avoiding the possibility of sanctioning/corrective actions, etc.
• Perform other duties/responsibilities as assigned.

Required Education and Experience

• Bachelor’s Degree Preferred
• Experience: 5-7 years firm managed care operations and/or compliance experience required.
• Preference to demonstrated experience with compliance program management and support for a managed care organization
• Experience working in a multifaceted health care environment, auditing and monitoring corrective action plans with a clear understanding of the associated rules, regulations and contractual requirements for Medicaid, CHIP and Medicare Programs preferred

Skills/Abilities:

• Knowledge of Medicaid, CHIP and Medicare requirements and the ability to analyze and interpret federal and state laws and regulations- required
• Ability to maintain confidentiality of audit findings, recommendations and penalties/sanctions- required
• Aptitude to research, analyze and successfully resolve a broad spectrum of issues- required
• Ability to observe and understand multiple business processes and identify risk and opportunities- required
• Ability to handle multiple responsibilities and changing priorities- required
• Ability to accept and manage multiple priority issues/assignments and work autonomously without continual intervention by management to complete tasks- required
• Outstanding written, oral and presentation skills as well as the ability to effectively deal with all levels of management- required
• Ability to quickly learn and implement knowledge of new technical processes- required
• Strong problem-solving skills and ability to identify issues in plan or delegated entity operations, administrative activities, and other areas which could result in non- compliance with CMS, DHS or plan requirements- required
• Ability to work independently and collaboratively with internal departments- required
• Ability to participate as a team player to meet all work requests/deadlines within standards to contribute to the organization’s overall performance- required
• Ability to provide continual updates to management on all issues, bringing those with potential impact to the attention of management immediately- required
• Advanced computer skills and proficiency in Microsoft Office Suite (e.g. MS Word, Excel, PowerPoint, etc.) required.