Address
Form of workFLSA Status: Exempt
Department: Compliance
Reports To: Compliance Officer
GENERAL DESCRIPTION OF POSITION
The Medicare Compliance Program Manager administers and oversees Santa Clara Family Health Plan's (SCFHP) Compliance Program for its Medicare line of business. The Medicare Compliance Program Manager supports the oversight and management of the Compliance Program, implemented to ensure that SCFHP and its first-tier, downstream and related entities (FDRs) consistently operate in accordance with all applicable federal and state laws, regulations and regulatory guidance.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.
1. Maintain proficiency with Medicare Part C and Part D regulations, Medicare Managed Care Manuals, sub-regulatory DHCS, DMHC, and CMS guidance and knowledge of SCFHP operations.
2. Work with the Compliance team colleagues to create and maintain an effective Medicare Compliance Program, including processes for the review, analysis and stratification of compliance risks and issues.
3. Provide routine updates regarding compliance performance concerns and risks to the Compliance Officer, including supporting technical and analytical information as needed.
Work with the Compliance Officer in the creation, maintenance and implementation of HPMS memos, policies, procedures and compliance documents.
5. Support and/or lead internal and external audits, and prepare internal business partners, vendors and delegates for audits, data reporting, and data validation activities to ensure the best possible outcomes.
6. Provide oversight and direction for SCFHP's Fraud, Waste and Abuse (FWA) program, including but not limited to coordinating reporting and investigations of allegations of FWA received via the hotline and other reporting mechanisms and facilitating the SIU's outreach to applicable parties to obtain additional information. Support all efforts to encourage managers and employees to report program noncompliance and suspected Fraud Waste and Abuse (FWA) and other misconduct without fear of retaliation
7. Create and manage a Compliance Program calendar and submit all required regulatory filings in a timely manner. Ensure completion of deliverables within required timeframes.
8. Support the investigation of Privacy/Security issues at the direction of the Compliance Officer and/or Privacy Officer.
9. Collaborate with Human Resources to ensure that covered persons are checked against the Office of Inspector General (OIG) exclusion lists and General Services Administration (GSA) debarment lists monthly and FDR attestation/certifications are signed.
10. Create and deliver general and specialized educational training programs to ensure that officers, directors, managers, employees, temporary staff, volunteers, and FDRs are knowledgeable about and have access to SCFHP's Compliance Program, written Standards of Conduct, compliance policies and procedures, and all applicable statutory and regulatory requirements.
11. Oversee development and implementation of business unit Corrective Action Plans (CAPs) to bring areas of concern into compliance.
12. Serve as a point of contact, and establish effective lines of communication with CMS and DHCS program/account managers.
13. Perform other related duties as required or assigned.
REQUIREMENTS - Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
1. Bachelor's Degree in Health Care Administration, Business Administration, Communications or related field, or equivalent experience, training or coursework. (R)
2. Minimum two years of Medicare compliance experience in a managed care environment. (R)
3. Medicare Part C and D expertise, including demonstrable knowledge of Medicare regulations, guidelines, audit protocols and processes. (R)
4. Ability to convey complex information in a meaningful way to a variety of audiences. (R)
5. Ability to establish, nurture and maintain strong and effective working relationships with the SCFHP staff, governmental and regulatory staff, legal counsel, and others. (R)
6. Prior experience with CMS Program and/or other audits. (D)
7. Broad and detailed knowledge of health plan operations and best practices (D)
8. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
9. Working knowledge and the ability to efficiently operate all applicable computer software including a working knowledge of computer applications such as Outlook, Word, Excel and PowerPoint. Ability to learn how to expertly use the Health Plan's core database software. (R)
10. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
11. Excellent communications skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments and outside entities over the telephone, in person or in writing. (R)
12. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
13. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
14. Ability to maintain confidentiality. (R)
15. Ability to comply with all SCFHP policies and procedures. (R)
16. Ability to perform the job safely with respect to others, to property, and to individual safety. (R)
PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:
ENVIRONMENTAL CONDITIONS
General office conditions. May be exposed to moderate noise levels.
Department: Compliance
Reports To: Compliance Officer
GENERAL DESCRIPTION OF POSITION
The Medicare Compliance Program Manager administers and oversees Santa Clara Family Health Plan's (SCFHP) Compliance Program for its Medicare line of business. The Medicare Compliance Program Manager supports the oversight and management of the Compliance Program, implemented to ensure that SCFHP and its first-tier, downstream and related entities (FDRs) consistently operate in accordance with all applicable federal and state laws, regulations and regulatory guidance.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.
1. Maintain proficiency with Medicare Part C and Part D regulations, Medicare Managed Care Manuals, sub-regulatory DHCS, DMHC, and CMS guidance and knowledge of SCFHP operations.
2. Work with the Compliance team colleagues to create and maintain an effective Medicare Compliance Program, including processes for the review, analysis and stratification of compliance risks and issues.
3. Provide routine updates regarding compliance performance concerns and risks to the Compliance Officer, including supporting technical and analytical information as needed.
Work with the Compliance Officer in the creation, maintenance and implementation of HPMS memos, policies, procedures and compliance documents.
5. Support and/or lead internal and external audits, and prepare internal business partners, vendors and delegates for audits, data reporting, and data validation activities to ensure the best possible outcomes.
6. Provide oversight and direction for SCFHP's Fraud, Waste and Abuse (FWA) program, including but not limited to coordinating reporting and investigations of allegations of FWA received via the hotline and other reporting mechanisms and facilitating the SIU's outreach to applicable parties to obtain additional information. Support all efforts to encourage managers and employees to report program noncompliance and suspected Fraud Waste and Abuse (FWA) and other misconduct without fear of retaliation
7. Create and manage a Compliance Program calendar and submit all required regulatory filings in a timely manner. Ensure completion of deliverables within required timeframes.
8. Support the investigation of Privacy/Security issues at the direction of the Compliance Officer and/or Privacy Officer.
9. Collaborate with Human Resources to ensure that covered persons are checked against the Office of Inspector General (OIG) exclusion lists and General Services Administration (GSA) debarment lists monthly and FDR attestation/certifications are signed.
10. Create and deliver general and specialized educational training programs to ensure that officers, directors, managers, employees, temporary staff, volunteers, and FDRs are knowledgeable about and have access to SCFHP's Compliance Program, written Standards of Conduct, compliance policies and procedures, and all applicable statutory and regulatory requirements.
11. Oversee development and implementation of business unit Corrective Action Plans (CAPs) to bring areas of concern into compliance.
12. Serve as a point of contact, and establish effective lines of communication with CMS and DHCS program/account managers.
13. Perform other related duties as required or assigned.
REQUIREMENTS - Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
1. Bachelor's Degree in Health Care Administration, Business Administration, Communications or related field, or equivalent experience, training or coursework. (R)
2. Minimum two years of Medicare compliance experience in a managed care environment. (R)
3. Medicare Part C and D expertise, including demonstrable knowledge of Medicare regulations, guidelines, audit protocols and processes. (R)
4. Ability to convey complex information in a meaningful way to a variety of audiences. (R)
5. Ability to establish, nurture and maintain strong and effective working relationships with the SCFHP staff, governmental and regulatory staff, legal counsel, and others. (R)
6. Prior experience with CMS Program and/or other audits. (D)
7. Broad and detailed knowledge of health plan operations and best practices (D)
8. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
9. Working knowledge and the ability to efficiently operate all applicable computer software including a working knowledge of computer applications such as Outlook, Word, Excel and PowerPoint. Ability to learn how to expertly use the Health Plan's core database software. (R)
10. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
11. Excellent communications skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments and outside entities over the telephone, in person or in writing. (R)
12. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
13. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
14. Ability to maintain confidentiality. (R)
15. Ability to comply with all SCFHP policies and procedures. (R)
16. Ability to perform the job safely with respect to others, to property, and to individual safety. (R)
PHYSICAL REQUIREMENTS
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)
- Reasoning 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)
ENVIRONMENTAL CONDITIONS
General office conditions. May be exposed to moderate noise levels.
