job
Director of Compliance
Overview
In collaboration with staff across all disciplines and departments, the Director of Compliance is responsible for developing and overseeing the health plan compliance program including planning, development, implementing, training, and on-going maintenance to ensure that the compliance program aligns with federal, state and industry regulatory guidelines, contractual requirements, and industry best practice standards.
Key responsibilities include oversight and management of all compliance requirements, including risk management, internal audits, delegated subcontractor audits, regulatory audits, compliance plan, fraud, waste and abuse plan, and privacy. Responsible for identifying and responding to regulatory requirements/requests from (but not limited to) the Texas Health and Human Services Commission (HHSC), Texas Department of Insurance (TDI), the Office of Inspector General (OIG), as well as the Centers for Medicare and Medicaid (CMS).
This position reports directly to the Sendero President & CEO, with matrix oversight by the Central Health compliance leader, and a dotted line to the health plan Board of Managers.
This position is considered Hybrid, which means that individuals in this position may work both at an approved Offsite location and Onsite at a primary location or multiple locations based on Business Needs.
Responsibilities
Essential Duties:
• Overseeing the health plan’s compliance and fraud, waste and abuse activities.
• Monitoring changes in state and federal laws, rules and regulations, interpret impact on the health plan and ensure implementation and tracking of any needed changes.
• Coordinating health plan efforts to meet all regulatory deliverable deadlines.
• Developing and maintaining a risk management program for the health plan.
• Conducting annual internal (departmental) and delegated audits.
• Developing and maintaining collaborative working relationships with regulatory agencies, delegated subcontractors and health plan staff.
• Serve as administrator for the health plan’s Compliance and Ethics Hotline.
• Investigate compliance incidents, including allegations of fraud, waste and abuse or other misconduct and HIPAA privacy and security incidents and coordinate follow-up activities, such as training and education, and recommendations to the Compliance Committee.
• As needed, collaborate on strategy and policy development with other operating units and leadership.
• Chair the health plan Compliance Committee, and as appropriate, participate on other internal committees.
• Lead and direct health plan compliance staff. Develop skills of health plan compliance staff, provide mentoring and support to health plan compliance staff.
• Provide oversight and manage the health plan’s vendor and/or subcontractor contract agreements.
• Perform other duties as assigned.
Knowledge/Skills/Abilities:
• Expert knowledge and understanding of compliance requirements for Medicaid, Medicaid managed care, Medicare, Marketplace, and other lines of business.
• Exceptional interpersonal skills with ability to interface effectively both internally and externally with a wide range of people including regulatory officials, vendors, and other health plan staff.
• Demonstrated experience in reading and interpreting laws and regulations, spotting trends and facilitating development of appropriate responses with other health plan staff, vendors and regulatory agencies.
• Familiarity with and understanding of the Texas HHSC Uniform Managed Care Manual and HHSC contract terms and conditions.
• Excellent problem solving skills with effective follow through.
• Strong listening, verbal, presentation, and written communication skills.
People Management/Department Management/Business Unit Management:
• Direct service line operations and execution of initiatives, goals and programs.
• Manage implementation of new service line initiatives and ensure coordination of strategy and initiatives.
• Participates as member of company Leadership team.
• Provides oversight and direction of departmental efforts.
• Develops and oversees departmental strategy to meet and support the strategic plan and business plan.
• Builds and maintains a superior departmental support team serving all employees in a manner that is consistent with the company’s Core Beliefs.
• Directs, supports, and coaches direct reports.
• Responds proactively to employee needs and concerns.
• Develops “experts” and “expertise” throughout the department and seeks employee input.
• Minimizes staff turnover.
• Acknowledges and rewards employees’ strengths and accomplishments.
• Evaluates assigned staff performance and competency, providing direct feedback.
• Assesses learning needs, develops competency plans and provides opportunities for learning.
Qualifications
Minimum Education: Bachelor’s Degree or equivalent experience
Preferred Education: N/A
Minimum Experience: 5 years of progressive professional experience involving regulatory oversight or compliance in Managed Care.
Preferred Experience: Managed Care Compliance experience highly desired, and legal experience desired.
Required Certifications/Licensure: N/A
Preferred Certifications/Licensure: Certified in Healthcare Compliance (CHC)
Required Courses/Completions (e.g., CPR): N/A