Regional Director - Managed Care Compliance

Description

This position oversees daily compliance activities and serves as the primary contact for health plan and regulator audit activities. They coordinate with departments (e.g., Corporate Integrity, Privacy, Security, EIS, etc.) to keep apprised of related program activities and updates to program documents. In this role, the Regional Director, Managed Care Compliance implements effective compliance programs adhering to the Centers for Medicare & Medicaid Services (CMS) requirements for providers to prevent, detect, and correct program noncompliance, as well as fraud, waste, and abuse (FWA).

They serve as the hub for all internal and external compliance concerns, compliance reporting, and compliance training associated with managed care operations. This individual will also coordinate policies and procedures, training and education, delegation oversight activities by business unit owners of first-tier, downstream and related entities (FDRs) that are considered delegated for a Medicare function and auditing. Specific business unit / functions (e.g., credentialing, UM, case management, claims, etc.) will be supported by subject matter experts ("SMEs") within their respective departments who are responsible for operational compliance, with direct accountability to the departmental

PRIMARY DUTIES AND RESPONSIBILITIES :

• Establishes and coordinates an effective, comprehensive Managed Care Compliance Program in accordance with federal, state and health plan requirements for all enterprise managed care operations. Oversees all aspects of the Managed Care Compliance Program, and works to enhance existing compliance programming, developing new policies and procedures and monitoring existing policies and procedures as appropriate to ensure full compliance with applicable laws, regulations, accrediting organizations and contractual obligations.
• Oversees Policy and Procedure Management which includes ensuring that compliance policies and procedures within managed care operations are up to date, including the FDR policy. Ensures providers receive and understand these policies and provide evidence to health plan that the policies were distributed and received by providers.
• Provides leadership, training and support to all direct reports, and provides daily supervision of Compliance Department staff.
• Working in collaboration with business unit owners, ensures policies and procedures related to delegated operations are compliant with regulatory, accrediting body and contractual requirements.
• Serves as the primary compliance contact for external stakeholders, including the health plans, accreditation bodies and regulators.
• Manage Compliance Department's administrative duties, including but not limited to organizing and maintaining complete department files, records, documentation, project plans and calendars.
• Prepares comprehensive, timely executive-level reports with regular cadence to keep leadership aware of audit status, compliance risks, etc.
• Fully and timely report to all appropriate leaders and staff of upcoming audits audit results, corrective actions so that the enterprise is fully prepared for optimal audit performance.
• Identifies potential areas of compliance vulnerability and risk and prepares annual
• Compliance Risk Assessment that identifies these risks. Works with operational leaders and SMEs to develop mitigation plans to address as appropriate.
• Identifies training needs and facilitates training for network providers related to compliance requirements and health plan required trainings (e.g., Model of Care, Special Needs Plans, etc.)
• Plans and works with Compliance Department staff and internal business owners to prepare for and coordinate health plan, CMS, DMHC and DHCS compliance audits to ensure successful audit performance and maintenance of full delegation status.
• Oversees, reviews, approves and assists Compliance Department staff in the preparation and management of audit submissions, attestations, and related corrective action plans to resolution with the health plans.
• Ensures Compliance Department staff collaborate with internal business unit owners to successfully respond to and execute all corrective actions. Reviews completed corrective action plans and conducts validation reviews to ensure mitigation.
• Establishes channels for reporting compliance concerns and required reporting of privacy and security breaches to health plans, per contractual terms.
• Keeps providers, colleagues and staff informed regarding compliance updates and expectations.
• Monitors pending and new legislation, federal and State regulatory requirements, industry standards, All Plan Letters (DMHC and DHCS), accrediting organization changes, which may impact the enterprise managed care operations. Keeps leadership and teams abreast of relevant impacts.
• Serves as Managed Care Compliance Officer for Torrance Memorial and Cedars-Sinai Medical Network operations

Job Requirements :

Salary : $140,000 - $244,000