Chief Regulatory Affairs & Compliance Officer

Job Description

Job Description

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

At this time, The Health Plan does not sponsor visa. Candidates must have legal and valid work authorization, Green Card or U.S. citizenship.

What You Will Be Doing:

Under limited supervision, the Chief Regulatory Affairs and Compliance Officer is responsible for establishing and implementing an effective regulatory affairs and compliance program, including fraud, waste and abuse, to prevent illegal, unethical or improper conduct consistent with applicable laws, regulatory and accreditation standards and HPSJ policies. Oversight of Health Plan’s legal department and management of outside counsel. Work is varied and complex and requires a high degree of discretion and independent judgment.

Supervises

Compliance Directors

Managers

Key individual contributors

Legal department staff

Essential Functions:

• Oversee the selection, retention, management and evaluation of all outside counsel.
• Recommends, develops and defines the health plan’s policies and procedures.
• Provides guidance on the legal impact of new or proposed local, state, federal or managed care legislation, changes in government agency requirements, business decisions, or processes that impact the health plan in the administration of its programs.
• Evaluates and plans for remediates enterprise risk related matters as issues and initiatives arise.
• Processes resolutions and executes major legal action regarding the HPSJ’s public entity status as it relates to jurisdiction, function, procedures, operations and responsibilities.
• Develops and maintains relationships with internal and external stakeholders, including federal and state regulators and trade associations.
• Identifies, develops, and implements or oversees the implementation of strategies; oversees the development of associated business plans.
• Develops and is responsible for the implementation and oversight of HPSJ’s Compliance Program, Anti-Fraud Plan, and Annual Compliance Work Plan.
• Chairs the Compliance Committee and ensures the committee meets the goals as outlined in the HPSJ Compliance Plan and Annual Compliance Work Plan; ensures all sub-committees to the Compliance Committees (when necessary) are formed and operate on a regular basis to meet their intent.
• Monitors the performance of the compliance program, including privacy and fraud, waste and abuse, and related activities on a continuing basis.
• Reviews, analyzes, or oversees the review and analysis of legislation, regulations, and regulatory guidance (e.g., All Plan Letters) to determine the impact on plan operations; identifies the need for new or revised policies, procedures, plan documents, etc.; makes recommendations to management; develops and implements as required.
• Develops and implements communication and educational programs and activities for internal and external stakeholders on compliance, and regulatory and contract requirements in an effective and timely manner.
• Conducts investigation of actual and potential privacy and fraud, waste, and abuse violations by HPSJ employees, vendors, and business associates; determines actions to mitigate violations and breaches; documents and reports to Executive Management or applicable regulators as required.
• Assists internal departments with the implementation, maintenance, and updates of compliance activities, including new and revised policies, procedures and corrective action plans.
• Leads the development and renewal of HPSJ’s state contracts and contract amendments.
• Develops, implements, and monitors vendor, administrative, and grant agreements/contracts processes.
• Plans for and oversees annual external audits; responds to, logs and tracks deficiencies; develops and monitors corrective action plans.
• Serves as the Health Plan’s Privacy Officer and Fraud Prevention Officer.
• Serves as the Health Plan’s contact for regulatory agency inquiries and issues; ensures that communication and responses are accurate and consistent.
• Oversees the identification, preparation, maintenance and monitoring of appropriate and required data, records, reports and other documentation; includes regulatory filings.
• Oversees the reviews and responses to requests and subpoenas for protected health information.
• Develops and conducts compliance and related training programs and activities for the Health Plan employees and vendors in an effective and timely manner.
• Fosters a work environment that respects the importance of the privacy of member, client, and employee information.
• Promotes, maintains, and ensures that direct reports promote and maintain an environment that supports HPSJs strategy, vision, mission, and values.
• Hires, develops, and retains, staff and ensures that direct reports hire, supervise, and retain competent staff.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• Expert knowledge of applicable federal and state privacy laws, regulations and standards, including state sponsored programs, applicable to health plans.
• In depth knowledge of health plan operations as they relate to compliance.
• In-depth knowledge of standard contract components and contract language specific to healthcare.
• In-depth knowledge of health information systems and their impact on privacy issues.
• In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
• Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies; identifies, plans, leads and executes to meet changing organizational and community needs, and regulatory requirements.
• Cultivates innovation: Creates new and better ways for the organization to be successful.
• Drives results: Consistently achieves results, even under tough circumstances.
• Drives engagement: Creates a climate where people are motivated to do their best to help the organization achieve its objectives.
• Drives vision and purpose: Paints a compelling picture of the vision and strategy that motivates others to action.
• Courage: Steps up to address difficult issues, says what needs to be said.
• Nimble learning: Actively learns through experimentation when tackling new problems, uses both successes and failures as learning fodder.
• Situational adaptability: Adapts approach and demeanor in real time to match the shifting demands of different situations.
• Strong skills in budget development and management.
• Communicates effectively: Develops and delivers multi-mode communications that convey a clear understanding of the unique needs of different audiences.
• Very strong presentation skills, with the ability to tailor presentations to a specific audience, and address and interact with large groups.
• Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with diverse individuals at all levels inside and outside of HPSJ.
• Very strong collaboration skills, with demonstrated ability to create and foster a collaborative work environment, maintain effective, high-performance teams, and organize people and resources to solve problems and identify business opportunities.
• Very strong assessment and analytical skills, including the ability to synthesize, distill concepts, draw conclusions and identify implications.
• Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.
• Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
• Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organizational goals.
• Very strong project management skills, with the ability to function as a sponsor and owner on complex projects; a track record of successful large project implementations.
• Strong customer service orientation.
• Ensures accountability: Holds self and others accountable to meet commitments.
• Strong knowledge of change management theory, with ability to anticipate and implement effectively.
• Promotes, maintains, and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values.
• Very strong coaching/counseling skills, including the ability to function as a mentor to management and employees.
• Ability to supervise staff and ensure that direct reports supervise staff in a manner that maximizes employee performance and business results.
• Ability to treat confidential information with appropriate discretion.

Preferred

• Familiarity with political, business, education, non-profit, and other community leaders in San Joaquin County and/or surrounding areas.
• Knowledge of the economic and healthcare issues, and issues affecting the underserved in San Joaquin County and/or surrounding areas.
• Knowledge of the managed care industry, its products, services and major business processes.
• Knowledge of federal and state and federal regulations applicable to managed care.

What You Have:

Education and Experience

Required

• At least eight years of healthcare regulatory experience; and
• Experience with Medi-Cal and/or Medicare managed care program requirements; and
• Experience working closely with internal and external leadership; and
• Six years as a Compliance Manager in a California health plan, including state-sponsored programs; and
• At least five years supervisory experience.
• Master's degree in Health Administration, Public Health, Regulatory Affairs, Business Administration, or other related fields.

Preferred

• Juris Doctor degree from accredited law school;
• Experience in an in-house legal setting, including managing outside counsel;

Licenses, Certifications

Required

• Certificate of Healthcare Compliance (CHC); Certified HealthCare Privacy Compliance (CHPC).

Preferred

• Current state bar license to practice law in the State of California.

What You Will Get:

HPSJ Perks:

• Robust and affordable medical coverage including HMO and PPO plan options
• Employee Wellness Program promoting physical, mental, and financial well-being
• Dental and vision plan with multiple provider choices
• Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan
• Two flexible spending accounts (FSAs)for healthcare and dependent care expenses
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Assistance Program (EAP)
• Health Advocacy to help you navigate medical care and benefits
• Voluntary supplemental benefits including medical, legal, identity theft protection
• Online discount mall
• Tuition reimbursement
• Remote work contingent on business needs and company guidelines
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do

Physical Demands

Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds.

Emotional/Psychological Demands

Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations.

Work Environment

Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards.

Important Notice : The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.