FLSA Status: Exempt
Reports To: VP, Government Relations and Compliance
GENERAL DESCRIPTION OF POSITION
The Compliance Officer oversees the compliance program and staff to ensure the Plan is compliant with applicable laws and regulations (including those related to Medicare, Medi-Cal, and Knox-Keene Act requirements), identifies and manages areas of risk, and maintains positive relationships with regulators and policymakers. This individual has direct access to the Chief Executive Officer and to the Santa Clara County Health Authority (SCCHA) Governing Board, for the purpose of advising and making recommendations about regulatory compliance issues. The scope of responsibilities includes serving as Privacy Officer and coordinating security matters with the Chief Information Officer, as well as coordinating compliance activities with Santa Clara Family Health Plan (SCFHP) operational areas.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.
- Provide strategic leadership to Compliance operations, including the development and distribution of written standards of conduct and policies and procedures that promote the organization’s commitment to, and culture of, compliance.
- Implement, document, and maintain a coordinated regulatory compliance program that meets regulatory expectations across all lines of business.
- Lead development and implementation of compliance training and education programs for all key stakeholders, establishing compliance expectations of Board members, staff, consultants, and First Tier, Downstream, and Related Entities (FDRs) to meet all applicable statutory and regulatory requirements.
- Determine the appropriate structure and staffing of the compliance function, and lead the compliance team by continuously engaging and developing compliance leaders and specialists, who work collaboratively with business units on cross-functional activities.
- Identify and assess areas of compliance risks, and develop work plans to address those identified as high risk.
- Ensure that business units develop and maintain key metrics monitoring compliance, especially with any area considered to be of high risk. Provide oversight and monitoring of operations through maintenance of a compliance dashboard reflecting organizational performance on Medi-Cal and Medicare regulatory requirements.
- Ensure that policies, procedures, and practices are designed to promote compliance with the requirements set forth by regulators, including oversight of all FDRs, and screening of all required stakeholders against appropriate regulatory databases.
- Serve as subject matter expert on compliance matters for SCFHP staff. Develop positive and effective lines of internal communication, and provide real-time guidance to business unit leadership related to translation of regulatory requirements and changes (e.g., dissemination of HPMS memos, APLs, and DPLs).
- Develop a robust audit program to monitor internal departments and external delegated entities to ensure compliance with applicable regulations, policies, and OIG elements of an effective compliance program.
- Develop a robust Fraud Waste and Abuse (FWA) program, and encourage staff to report noncompliance, FWA, and other misconduct without fear of retaliation and with an opportunity for anonymity.
- Provide oversight and maintenance of the compliance hotline, and processes to receive and resolve complaints and concerns, including investigations of alleged regulatory and policy violations.
- Organize and support the Compliance Committee structure. Communicate effectively with the SCFHP CEO and Chair of the SCCHA Board Compliance Committee.
- Develop and communicate annual compliance risk assessments and audit work plans, and make periodic reports of progress toward plans.
- Develop positive and productive relationships with regulators to foster partnership on regulatory issues and promote the Plan’s position as a respected stakeholder. Ensure timely and accurate regulatory reporting, responses, and corrective actions.
- Coordinate external regulatory audits including those by CMS, the California Department of Health Care Services (DHCS), and the California Department of Managed Health Care (DMHC), as well as any required remediation and/or corrective action plans.
- Oversee, follow up and, as applicable, implement corrective actions to investigations and other issues generated by the compliance program.
- Advise the CEO on anticipated regulatory changes and potential impact to benefit programs and the organizational profile.
- Provide compliance reports at least quarterly to the Governing Board on the status of the compliance program, the identification and resolution of potential or actual instances of noncompliance, and external regulatory audits.
- Carries out supervisory responsibilities in accordance with the organization’s policies, procedures, applicable regulations and laws. Responsibilities include:
- Recruiting, interviewing, and making recommendations for hiring.
- Developing a high performing department, culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives.
- Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance.
- Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees’ needs, ensuring they have the necessary resources to do their work.
- Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews.
REQUIREMENTS – Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
- Bachelor’s degree in Healthcare Administration, Public Health, Business, or related field. (R)
- Masters or Juris Doctor (JD) degree. (D)
- Certification in compliance field by organizations such as the Health Care Compliance Association (HCCA) or National Health Care Anti-Fraud Association (NHCAA). (D)
- Minimum of five years of related experience leading a managed care compliance program that meets federal and state requirements. (R)
- Minimum of five years of experience in management positions demonstrating increased levels of accountability. (R)
- Previous Medicare, Medicaid, and HIPAA regulatory experience in a managed care entity. (R)
- Previous Medi-Cal compliance experience. (D)
- Previous experience working with federal and state regulators on compliance-related issues. (R)
- Compliance experience related to oversight of delegated entities in government-sponsored insurance products (CMS, Medicaid, Medicare). (D)
- Previous experience supporting a compliance committee structure and working with a governing board. (R)
- Knowledge of managed care external accreditation requirements (National Committee on Quality Assurance). (D)
- Ability to evaluate, interpret, and apply practical implications of applicable rules, laws, regulations, program requirements, and industry guidance and evaluate priorities. (R)
- High integrity and sense of ethics. (R)
- Demonstrate initiative and willingness to learn. (R)
- Leadership skills, ability to coach and mentor. (R)
- Ability to foster a cohesive and supportive team environment. (R)
- Demonstrated ability to establish, nurture, and maintain strong and effective working relationships with cross-departmental staff, governmental and regulatory representatives, and others. (R)
- Flexibility and adaptability to changing business needs. (R)
- Accountability for results and execution. (R)
- Public speaking and presentation skills. (R)
- Ability to gather and analyze data, organize and write reports, and organize work efficiently. (R)
- Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
- Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
- Ability to maintain confidentiality. (R)
- Accepts and respects diversity without judgment. (R)
- Ability to comply with all SCFHP policies and procedures. (R)
- Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and PowerPoint. (R)
- Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
- Ability to perform the job safely and with respect to others, to property and to individual safety. (R)
Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:
- Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
- Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
- Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
- Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
- Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
- Emotional/Psychological Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)
All applicants upon receipt of a conditional offer of employment must provide proof of the COVID-19 vaccination. Requests for reasonable accommodation will be considered consistent with state and federal law.
In accordance with Santa Clara Family Health Plan’s (SCFHP) duty to provide and maintain a workplace that is free of known hazards, we are committed to safeguard the health of our employees and their families, our members and the community at large from infectious diseases, such as COVID-19 that may be reduced by a vaccination. SCFHP complies with all applicable public health laws and guidance from the Centers for Disease Control and Prevention and local public health authorities as applicable.