Under the general direction of the Compliance Manager, this position is responsible for supporting the Alameda Alliance for Health’s Compliance program, with an emphasis on external and internal auditing activities. This position will support the HIPAA and Fraud, Waste, and Abuse programs to ensure all reported incidents are fully investigated and reported to the regulatory agencies.
Principal responsibilities include:
· Lead and/or coordinate internal audits to ensure compliance with regulations and controls by examining and analyzing records, reports, operating practices and documentation.
- Recommend opportunities to strengthen the internal control structure.
- Develop and prepareaudit tools, findings and reports, and corrective action plans.
- Analysis data reports for trends and select case samples for auditing.
- Prepare special audit reports by collecting, analyzing, and summarizing operating information and trends.
- Provide management audit and other reports by collecting, analyzing, and summarizing management information.
- Regularly schedule and attend meetings with management to communicate audit findings, discuss identified risks, and explore suitable solutions.
- Lead and participate in the development and monitoring of corrective action plans resulting from audits to mitigate risks.
· Lead and/or coordinate external audits to ensure compliance with regulatory and contractual requirements.
- Coordinate with external regulatory agencies and Alliance’s internal departments on documentation requests and submissions, preparing for audit onsite visits, and corrective action plan responses.
- Coordinates the delegation annual auditing procedures including scheduling, creating audit tools, audit reports, and corrective action plan documents.
· Act as back-up liaison between state and federal agencies/individuals and Alliance’s staff and senior management. Assist in the development of Alliance’s policies and procedures and monitoring of the annual policy review process.
- Train and assist various departments in developing best practices in their operations in accordance with established policies and procedures.
- Assist in reviewing policies for updating to include regulatory standards.
- Track policies to ensure all are reviewed annually by departments.
· Assist in the investigation and research of compliance issues, such as allegations of HIPAA violations, fraud waste and abuse, and other compliance issues.
- Research incidents reported to the Compliance department and gather supporting case documentation.
- Track and document all case incidents reported until fully resolved.
- Report incidents to the apprropriate regulaotry agencies within the required timeframes.
· Ensures delegated entity’s compliance with reporting requirements by tracking the receipt and completeness of reports.
- Analyzes and reviews delegated reporting from delegated entities and create performance dashboards
- Works with internal departments to develop and maintain delegation agreements and assessment tools
· Maintain a strong working knowledge of state and federal legislation, statutes and regulations, and local, state, and national health issues affecting publicly-funded managed care organizations and the Alliance.
- Maintain knowledge of business products and related Alliance policies and procedures.
- Research and interpret Knox-Keene Act, Title 22 and Department of Health Care Services (DHCS) regulations.
- Monitor regulatory/compliance climate and escalate issues when necessary.
· Complete other special projects and duties as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
· Audit various business/department processes.
· Develop audit program including audit tools, audit reports, and criteria metrics.
· Coordinate external audits with regulatory agencies, delegated entities, and internal departments.
· Research, interpret, and provide analysis of state and federal legislation, statutes and regulations as applicable to company policies and procedures.
· Communicate effectively and efficiently internally and externally.
· Comply with, and support the organization’s compliance with, the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
· Constant and close visual work at desk or computer.
· Constant sitting and working at desk.
· Constant data entry using keyboard and/or mouse.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
· Frequent walking and standing.
· Occasional driving of automobiles.
EDUCATION OR TRAINING EQUIVALENT TO:
· Bachelors of Arts or Bachelors of Science degree required.
· Familiarity with Medicaid (Medi-Cal), Knox-Keene Act, and other publicly funded programs preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Two years of experience in health care, auditing, compliance, regulatory, investigation, and/or insurance/managed care experience required.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Exemplary interpersonal skills, including ability to work effectively as part of a team across organizational structure.
· Ability to analyze and interpret legislative, statutory, regulatory, and legal language.
· Strong analytical problem solving skills with initiative.
· Ability to work independently is critical.
· Strong organizational/documentation skills.
· Strong project management experience preferred.
· Ability to meet deadlines and adjust to changes in policies, procedures, and priorities.
· Effective verbal and written communications skills.
· Ability and willingness to take initiative to address problems and make continuous process improvements.
· Ability to enforce and educate staff in Compliance areas, including established ethics and codes of conduct.
· Ability to interface with senior management and translate complex issues into project plans with deliverables and measurable outcomes.
· Proficient experience/comfort in use of computer software. Microsoft Word, Excel, Outlook, and PowerPoint as well as internet search skills mandatory.