Director of Compliance

It's inspiring to work with a company where people truly BELIEVE in what they're doing!

When you become part of the CareNu Team, you'll realize it's more than a job. It's a mission. We're committed to providing groundbreaking solutions for our clients' unique needs offering a wide variety of compassionate healthcare choices. Our employees make all the difference in our success!

Role:
The Director of Compliance is responsible and accountable for overall implementation, evaluation and monitoring of the Compliance Program and Plan for CareNu which will include compliance oversight over all of its subsidiaries. The Director works with various levels of leadership and staff to ensure compliance with state and federal regulations and statutes.
Establish a specifically designed compliance program that effectively prevents and/or detects violation of applicable laws and regulations, which will protect the Business from liability of fraudulent or abusive practices. Ensures that the Business understands and complies with applicable laws and regulations pertaining to the Health Care environment. Ensures the Business' accountability across all business lines.

Qualifications:

• Bachelor's degree in a related field
• Minimum of five (5) years' prior Medicare Advantage payor / managed care experience preferably in compliance and/or quality management experience with comprehensive knowledge and understanding of CMS, CMMI, NCQA or AAAHC and URAC Credentialing, Delegation and Quality Improvement
• Prior work experience with conducting audits and understanding of auditing methodologies.
• Certification by the Healthcare Compliance Association strongly preferred.
• Strong business foundation with proven analytical and problem-solving skills
• Demonstrated skills in fiscal management, utilization of analytical and statistical tools, data analysis, and outcomes management.
• Federal and state regulation knowledge and ability to stay current with updates.
• Able to communicate effectively (written and verbal) in English.
• Excellent skills in management of group dynamics and conflict resolution
• Knowledge of and ability to apply process improvement theory and process mapping.
• Computer knowledgeable and competent with statistical applications and graphics
• Intermittent Driver - Valid driver's license and automobile insurance per Company policy
• Able to travel to off-site locations.
• Able to work with minimal supervision and exercise a high degree of discretion and independent judgment.
• Able to prioritize multiple job responsibilities, exercise critical thinking skills, and effectively handle stress.

Competencies:

• Satisfactory completion of competency requirements for this position.

Responsibilities of all employees:

• Always represent the Company professionally through care delivered and/or services provided to all clients.
• Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
• Comply with Company policies, procedures and standard practices.
• Observe the Company's health, safety and security practices.
• Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
• Use resources in a fiscally responsible manner.
• Promote the Company through participation in community and professional organizations.
• Participate proactively in improving performance at the organizational, departmental and individual levels.
• Improve own professional knowledge and skill level.
• Advance electronic media skills.
• Support Company research and educational activities.
• Share expertise with co-workers both formally and informally.
• Participate in Quality Assessment and Performance Improvement activities as appropriate for the position.

Leadership Success Factors:

• Communication. Express thoughts and ideas clearly. Adapt communication style to fit audience.
• Initiative. Originate action to achieve goals.
• Management Identification. Identify with and accept the problems and responsibilities of management.
• Judgment. Make realistic decisions based on logical assumptions, information facts and in consideration of organizational resources.
• Planning, Organizing and Controlling. Establish course of action for self and/or others to accomplish a specific goal, plan proper assignments of personnel and appropriate allocation of resources. Monitor results.
• Leadership. Use appropriate interpersonal styles and methods in guiding others.
• Work Standards. Set high goals or standards of performance for self and others. Compel others to perform.
• Tolerance for Stress. Maintain stability of performance under pressure and/or opposition.
• Innovativeness. Generates and/or recognizes imaginative, creative solutions in work related situations.
• Delegation. Allocate decision making and other responsibilities effectively and appropriately.
• Staff Development. Develop the skills and competencies of subordinates.
• Organizational Sensitivity. Perceive the impact and the implications of decisions on other components of the Organization.
• Ethics. Model highest standards of conduct and ethical behavior, adopting a strong position against fraud and abuse.
• Regulatory Compliance: Educate and monitor staff regarding their own and the organization's responsibilities for regulatory compliance with CMS/Joint Commission, Agency for Health Care Administration, and any other federal, state, or local agencies.

Job Responsibilities:

• Directs all activities related to the Corporate Compliance Program, Plan, Code of Conduct and Waste and Absue Plan across the enterprise while ensuring compliance with governmental requirements.
• Spearheads development and implementation of compliance policies and procedures and training programs across the organization.
• Interprets and disseminates information and compliance matters, including communications from CMS issued through the Health Plan Management System (HPMS).
• Works closely with executive management to create an annual audit plan based on areas of risk, as determined internally and by the Office of Inspector General (OIG); Office of Insurance Regulation and CMS.
• Oversees all activities performed by the Compliance Auditors, including audit tool development, ensuring accuracy and timeliness.
• Directs all billing adjustments, when necessary. Maintains an Administrative Adjustment Request Form (AARF) process allowing for tracking and trending causes.
• Directs all responses to all third-party audits. Oversees preparation of the Organization's responses for review by the President, and then, ensures submission of the response on time.
• Prepares all third-party appeals including Administrative Law judge (ALJ) cases.
• Manages compliance hotline process, which includes investigation, follow up, and corrective action, if necessary.
• Conducts external audits of health plan's delegated entities specific to delegated functions performed I accordance with CMS requirements for those functions.
• Provides input and representation on key compliance initiatives, meetings and committees.
• Stays abreast of industry and compliance trends and recommends and implements changes to internal company processes, as needed.
• Leads educational efforts around compliance, fraud, and abuse within the CMS mandated timeframes.
• Investigates and prepares responses/action plans for any Compliance-related occurrence or anonymous reports.
• Reports to the President and Board on a quarterly basis the status of health plan's compliance program, including high-risk issues.
• Serves as the HIPAA Privacy Officer; oversees medical record request process.
• Collaborates with the IT Security Officer on security protocols and breaches.
• Actively participates/leads in committees, as assigned.

Performs other duties as assigned.

Compensation Pay Range:
$106,962.49 - $167,128.89

This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.