Gateway Health Plan
Job Description :
JOB SUMMARY (Summarizes the major purpose and primary responsibilities)
This job is responsible for the implementation of the Medicare compliance program as required by Medicare Managed Care Manual Chapter 21 – Compliance Program Guidelines and Prescription Drug Benefit Manual Chapter 9 – Compliance Program Guidelines. This job defines the program structure, educational requirements, reporting, and complaint mechanisms, response and correction procedures, and compliance expectations of all personnel and first tier, downstream and related entities (FDRs). The incumbent has direct access to the governing bodies and compliance committee for the purpose of advising and making recommendations about regulatory compliance issues as well as direct access to numerous external sources including the Centers for Medicare & Medicaid Services (CMS) regional and central office, federal/state agencies, and trade associations. The incumbent must have extensive knowledge of the applicable federal and state rules as well as a solid working knowledge of managed care operations, compliance program structures, and audit methodologies. The incumbent must have the highest level of integrity and ethics and demonstrate professional representation of the company.
ESSENTIAL RESPONSIBILITIES (Describes the critical tasks, duties and responsibilities of the position.)
- Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
- Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
- Communicates effectively. This position inspires confidence in the state of the organization’s compliance through internal and external communication activities. Works effectively with others to achieve common goals and exercises effective interpersonal influence and stakeholder advisory skills. Facilitates process and project meetings and influences at various levels in the organization. Develop, solidify and enhance productive working relationships with regional and central office CMS staff and applicable trade organizations and advisors. Effectively summarize complex regulatory issues and guidance to senior management and governing bodies in order to solicit feedback and obtain buy-in on corporate strategies to maintain compliance. The compliance officer has express authority to provide unfiltered, in-person reports to the sponsor’s senior-most leaders and governing bodies.
- Provides Medicare compliance advisory services to the organization. This position is a strategic internal business partner serving as the subject matter resource for Medicare regulations and requirements. Routinely meets with corporate line management to assess business directions and the strategic direction of the company in order to partner on meeting corporate goals within the various regulatory parameters. Summarize and interpret regulatory requirements including developing and consulting on various compliant solutions to aid stakeholders in decision making. Keeps abreast of changing business needs and helps to identify areas of compliance curriculum redesign including oversight and training initiatives.
- Oversees implementation of new Medicare regulations. This position directs the activities related to new guidance released by CMS to ensure that the company’s internal and external initiatives are developed and executed successfully with the involvement of appropriate cross functional matrix partners as well as external vendors. Provide education and training about actual, proposed, or pending Medicare regulations that affect operations and identifying operational obstacles to compliance, and working with other employees to identify and implement solutions. Coordinate compliant solutions by regulatory deadlines as a lead in the Medicare implementation team accountable for the overall interpretation and implementation of regulatory deliverables and milestones. This includes partnering with the business stakeholders, the project management office, and P&L leaders to develop the business position, define solutions strategy, and ensure monitoring of core business activities. Provides advice, direction, and cooperation on a variety of divisional decisions regarding compliant solutions and services.
- Manages compliance issues. This position establishes and implements a system for promptly responding to compliance issues as they are raised, investigating potential compliance problems as identified in the course of self-evaluations and audits, and correcting such problems promptly and thoroughly to reduce the potential for recurrence. Perform complex analysis, comparing actual performance to regulatory requirements in order to identify gaps; examining process and technology issues or characteristics impacting compliant performance. Apply a broad knowledge of concepts and principles to develop analytical frameworks, approach and methodology best practices to analyze complex compliance issues, often applying ingenuity and originality to develop unique solutions. Uses questioning skill to gather pertinent information to identify gaps and analyze needs. Demonstrate and apply a thorough understanding of complex operational processes and/or complex information systems at the company.
- Executes Internal Audit & Monitoring Plan This position is responsible for designing a systematic approach to ensuring ongoing compliance with CMS requirements. Conduct the Medicare compliance risk assessment identifying and analyzing risks of potential noncompliance and methodically assessing organizational risk including likelihood of noncompliance and the broad range of impact if non compliant. Develop audit and monitoring work plan that is reflective of the organizations size, structure, risks and resources to assess performance in, at a minimum, areas identified as being at risk. Effectively manage assigned engagements on the Medicare compliance work plan, by addressing delays and removing barriers, as necessary. Propose modifications to the work plan based on evolving priorities, largely driven by enterprise and tactical risk evolution. Develop performance dashboard solutions that provide business leaders with critical metrics for effectively measuring and managing ongoing compliance.
- Manages external audits. This position for managing and controlling audits performed by governmental agencies and regulators or their contractors. Develop and maintain a strategy to manage audits by third parties (other than the independent auditors performing the audit of the company’s financial statements). The strategy should be designed to ensure that audits are performed in an efficient and effective way, minimizing disruption to the company and ensuring that appropriate data is provided to, or made available to, the auditors. The strategy should be evaluated periodically to ensure that emerging industry best practices are considered and that changes in the scope and nature of the audits are appropriately addressed. Prepare and provide status reporting for the internal customers, senior leadership and governing bodies on a recurring scheduled basis and as necessary. Build consensus internally to complete audits timely and gain action and support to address identified issues.
- Contributes to an effective corporate compliance program. This position partners with other senior leadership in the compliance division to establishment of an effective compliance program as outlined by the Office of Inspector General (OIG) and amended from time to time by subsequent CMS guidance. Ensuring that the DHHS OIG and Government Services Administration (GSA) exclusion lists have been checked for all applicable individuals. Creating and coordinating, by appropriate delegation, if desired, educational training programs. Maintaining the compliance reporting mechanism and closely coordinating with the internal audit department and the SIU, where applicable. Responding to reports of potential FWA, including the coordination of internal investigations with the SIU or internal audit department and coordinating potential fraud investigations/referrals with the SIU, where applicable, and the appropriate NBI MEDIC. Develop and maintain policies and procedures to foster a culture of compliance; continually monitor and evaluate the adequacy and efficacy of policies, procedures and company adherence.
- Other duties as assigned or requested.
Bachelor’s Degree- Business, Healthcare, Public Policy, Accounting or other related area
Substitutions (Acceptable substitutions in lieu of a degree 1 ½ years’ experience = 1 year college)
Business, Healthcare, Public Policy, Accounting or other related area
Minimum: This section refers to the minimum years and type of applicable experience needed to perform the job. Minimum requirements must be non-comparative, objective, and relevant.
- 5-10 years’ of experience in health care compliance
- 5-10 years’ of progressive auditing experience
Preferred: This section refers to additional desired years and type of experience that the hiring manager would prefer, above and beyond the basic requirements of the job.
- 3-5 years’ of Medicare compliance experience
KNOWLEDGE, SKILLS & ABILITIES (List the attributes required to perform the job through demonstrated service, education or training)
- Broad-based business knowledge as well as in-depth knowledge of the insurance industry, strategic compliance planning, regulatory concerns, compliance requirements, and corporate integrity principles. The ability to comprehend and interpret regulatory, legislative, and contractual mandates
- Experience with managed care, Medicare and federal and/or state regulations, quality improvement and compliance oversight
- High-level of skill in leading interdepartmental and cross-functional strategy development; experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met. Simultaneously manage multiple projects
- Excellent oral, written, and presentation skills, as well as conceptual and analytic skills are necessary in order to review and articulate corporate objectives and Federal regulations across all relevant audiences
- The utmost integrity in the discreet and confidential handling of confidential materials is necessary
REQUIRED LICENSURE (Licenses that are required to perform the job)
Auditing or compliance certification such as CPA, CIA, CFE, CHC, or CCEP
TRAVEL REQUIREMENT: 0% – 25%
(List % of time traveling)
LANGUAGE REQUIREMENT (other than English)?
(List primary language)
PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
(The physical, mental demands and working conditions described here are representative of those that must be met by an employee to successfully perform the essential function of their job. Reasonable accommodations will be made when necessary to enable individuals with disabilities to perform the essential duties of the position, to the extent that they do not cause undue hardship.
An employee in this position works in an office environment. The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email). The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks. The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.
Teaches/Trains others regularly – Occasionally
Travels regularly from the office to various work sites or from site-to-site – Rarely
Works primarily out-of-the office selling products/services (Sales employees) – Does Not Apply
Physical Work Site Required – No
Most On-The-Road Positions
An employee in this position may work in a home or company office environment but is also frequently driving to and from various locations to perform the work off-site. The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email). The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks. The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.
An employee in this position is frequently required to move throughout the workplace, sit, stand and walk, use hands and fingers to hold objects, tools or controls, possess fine motor skills (e.g., to write and operate a computer or to steer transportation equipment), possess gross motor skills (e.g., to carry items), reach with hands and arms, climb stairs and ladders, balance, stoop, kneel crouch and crawl, communicate effectively, and talk and hear. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. The employee must be able to work in a busy environment where decisions often must be made quickly, must attend work on a regular and reliable basis, must adhere to all workplace policies, and may be called upon to work outside regular business hours. This work occurs in a [example: warehouse, hospital or provider’s office or mailroom].
Lifting: up to 10 pounds – Does Not Apply
Lifting: 10 to 25 pounds – Does Not Apply
Lifting: 25 to 50 pounds – Does Not Apply
Changes Approved By:
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies
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