Compliance Strategist

Santa Barbara, CA, United States

Job Details

Job Location :    Main Office - Santa Barbara, CA

Position Type :    Full Time

Salary Range :    Undisclosed

Job Category :    Compliance

Description Salary Range:   $101,007 - $151,510

Job Summary

The Compliance Strategist will lead the AMO in meeting regulatory requirements and business objectives through program development and strategic tactics, and through the preparation and filing of reports and related information required by state and federal agencies, and in the maintenance of an enterprise-wide compliance program. The Compliance Strategist will be expected to work with independence, using their subject matter expertise to make recommendations or decisions.

Duties & Responsibilities

Leads, manages, analyzes, and ensures cross-functional compliance with the California Department of Health Care Services (DHCS), California Department of Managed Health Care (DMHC), and Centers for Medicaid and Medicare Services (CMS) contractual requirements, state and federal regulations, state and federal program requirements, and NCQA accreditation standards.

Leads and manages the cross-functional planning and implementation of CMS, DMHC, and NCQA requirements to ensure compliance with contractual requirements, federal and state statutes and regulations, state and federal program requirements, and accreditation standards, through engagement with executive leadership, management, department leaders, and impacted stakeholders.

Is a SME on compliance interpretation, analysis, guidance, and education of health plan regulations to ensure compliance with contractual requirements, federal and state statutes and regulations, regulatory program requirements, and accreditation standards.

Reviews and analyzes state and federal statutes, regulations, and accreditation standards to determine impact, assess risk, and develops necessary recommendations to leadership.

Provides recommendations and guidance based on subject matter expertise to leadership, management, and stakeholders on remediation of areas of non- compliance.

Manages and ensures quality review process for documents submitted to regulatory and accreditation agencies.

Manages key deliverables and ensures timely submission to regulatory and accreditation agencies through cross-functional engagement.

Provides key contributions based on subject matter expertise to the development and maintenance of organizational and compliance policies and   procedures to ensure compliance with contractual requirements, federal and state regulatory requirements, regulatory program requirements, and current industry standards.

Leads and manages the preparation, quality review process, and filing of recurring and ad-hoc reports required to be submitted to DHCS, DMHC, CMS, NCQA, and other agencies through cross-functional engagement.

Leads and ensures timely submission of requested regulatory reports for internal and external reporting, and maintains a record of report submission to regulatory and accreditation agencies.

Maintains current awareness of healthcare and health plan compliance laws, regulations, and standards, as well as related industry developments in order to ensure continuous subject matter expertise.

Represents AMO in compliance program initiatives.

Reports up to Director for risk assessment and risk plan development.

Maintains AMO policies/procedures.

Other related projects and duties as may be assigned.

Primary external contacts include CMS, DMHC, DHCS, NCQA, other County Organized Health Systems and Medi-Cal plans, and industry organizations such as the California Alliance of Health Plans (CAHP) and Local Health Plans of California (LHPC).

Qualifications

Knowledge/Skills/Abilities

Advanced understanding principles of Medi-Cal managed care and regulatory, accreditation, and compliance processes impacting managed health care.

Advanced understanding of Medicare requirements, policies, and processes.

Strong understanding of federal and state regulatory and accreditation bodies and processes.

Understanding of CenCal Health’s operations and processes a plus.

Advanced ability to effectively prioritize multiple tasks and deadlines.

Advanced ability to effectively, clearly, and independently document, summarize, and resolve complex issues.

Advanced ability to analyze and interpret regulatory and contractual requirements.

Advanced ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position.

Advanced ability to develop and organize electronic and paper filing systems.

Advanced ability to accurately and effectively communicate, both orally and in writing.

Advanced ability to establish and maintain effective and cooperative working relationships with leadership, management, and staff.

Advanced ability to work under pressure to accurately complete tasks within established deadlines.

Applies principles and methods of planning, directing, and maintaining compliance with regulatory standards.

Applies principles and practices of managed care health care systems, medical administration, and NCQA accreditation and industry standards.

Demonstrates excellent problem-solving and analytical skills with high attention to detail.

Effectively manage and prioritize multiple concurrent projects.

Must have basic knowledge of Medi-Cal, Medicare, Knox-Keene, and NCQA.

Must have knowledge of and proficiency in the use of Microsoft Office suite of products (e.g., Word, Excel, Outlook, PowerPoint, SharePoint, Teams, Visio).

Must have knowledge of and proficiency in navigating contractual, regulatory, and accreditation guidance.

Must be comfortable with learning to use new computer systems as necessary to support Compliance programs (e.g., Smartsheet).

Education & Experience

Bachelor’s degree required (higher degree may substitute a year of experience).

Master’s degree in public health, public policy, or other related field is preferred.

Must have at least three (3) years of healthcare experience.

Must have at least two (2) years of experience:

Researching, compiling, and organizing information from various sources.

Working with regulatory or accreditation agencies.

The creation and preparation of reports and presentations.

Hosting stakeholder meetings.

With time and task management.

Healthcare Compliance Certification (preferred).

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