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Manager of Compliance

Date Posted: 5/15/2020

Job #1574119
Permanent
Louisville, Kentucky
Manager

 

  • Plans and manages compliance programs.
  • Manages and maintains good working relationships with DMS and manages all DMS requests through resolution and delegates tasks as needed to all levels of the organization and ensures timely response and/or report filing.
  • Acts as primary interface for operational issues, ensuring the continued involvement and collaborative effort between PHP, and Kentucky DMS and Kentucky Department of Insurance (DOI), as necessary.
  • Chairs the weekly DMS/HP/PHP IT meetings and attends regularly to participate and fully contribute on Passport’s behalf at the DMS/PHP Operations meeting.
  • Responsible for review of prepared reports, representation and participation with autonomous decision making for 80% or more on MFCU (DMS/OIG/OAG/DMS PIU and All MCOs) issues, requests, requirements. 
  • Demonstrates autonomous decision making for 80% of DMS requests (approximately 15 per week), statutory and contractual reporting on a periodic basis.  Works at the direction of the CCO and Director of Compliance.
  • Provides accurate and timely information to executive management to assist in decision-making.  Leads and/or participates at the direction of executive management regarding sensitive, proprietary, potential fine/penalty, orders from DMS, etc.
  • Directly responsible for management of all external audits including delegation of action items to internal departments, coordinating with delegation oversight manager to manage delegates action items, trains as needed, manages timelines and ensures deliverables meet the requirements of the audit. 
  • Chairs the auditor/PHP meetings and coordinates all operational and executive management interviews, etc.  Responsible for reporting to CCO, Compliance Committees, Senior Leadership and other groups as needed, the findings and action items of all external audits.  Collaborates with internal auditors as needed.
  • Establishes priorities and monitors progress of direct reports.  
  • Develops and maintains adherence to Compliance Plan relating to all related DMS required actions as well as individual team plans.
  • Directs the activities of Compliance Specialist and provides mentoring, guidance, productive feedback and imposes disciplinary actions, as needed.
  • Using PHP controls in P&Ps, acts autonomously to develop job descriptions, position justifications, and training for direct reports.  Collaborates with Human Resources and Director of Compliance as required by P&Ps.  Responsible for interviewing, selection of candidate and collaborating with Human Resources to onboard direct report(s).
  • Monitors state and federal laws to assure timely and accurate implementation of all mandated changes.
  • Monitors compliance status; ensures all team members meet deadlines for review and reporting responsibilities.  Provide formal updates to appropriate management.
  • Prepares updates on regulatory changes for Senior Management.  
  • Responsible for notifying Department of Medicaid Services (DMS) of company changes as required by state contract.  
  • Coordinates and Oversees annual external quality reviews with DMS.
  • Serves as the Program Integrity Coordinator pursuant to Kentucky laws.
  • Oversees Fraud and Abuse tracking and reporting.  Ensures the proactive identification of procedural or operational inefficiencies and implements corrective action, regardless of functional area.
  • Ensures consistency of established programs and management policies, procedures and protocols.  Establishes policies, procedures, and protocols if none exist.
  • Coordinates PHP investigative activities with Kentucky Office of Inspector General and Attorney General and federal investigators. Implements the HIPAA compliance efforts, leads appropriate resources, and determines project requirements and deliverables.
  • Develops processes, procedures and methods to achieve and maintain compliance with the HIPAA Privacy and Security regulations, including all amendments Provides information/education about privacy and security practices for protected health information.
  • Oversees the third party liability responsibilities of the state contract with appropriate PHP departments.
  • Oversees the subrogation responsibilities of the state contract with appropriate PHP departments.
  • Acts as primary interface for operational issues, ensuring the continued involvement and collaborative effort between PHP, and Kentucky DMS and Kentucky Department of Insurance (DOI), as necessary.
  • Takes appropriate action to ensure compliance with contracted policies and procedures.
  • Implements and maintains continuous process/quality improvement initiatives relating to compliance requirements, as directed, to ensure DMS satisfaction.
  • Responsible for education as a Compliance Liaison to assigned operational teams and manages direct report(s) prioritization through completion of their duties relating to their assigned operational teams.
  • Monitors both state and federal statutory and regulatory environment to identify actual changes, for Kentucky Department for Medicaid Services, Kentucky Office of Insurance, Kentucky Office of Inspector General, U.S. DHHS Center for Medicare and Medicaid Services, U.S. DHHS Office of Inspector General and assures appropriate areas are informed. 
  • Reengineers critical business processes to remove any disconnects and improve both accuracy and efficiency with regard to online benefits and all business associated with administering benefits, including benefit interpretation.
  • Develops and implements compliance plan, including fraud and abuse detection, third party liability, subrogation, and comprehensive compliance training for company-wide staffing.  
  • Oversees HIPAA compliance, and assists with other areas implementation of HIPAA requirements.
  • Ensures quality and timeliness of all statutory reporting for the Health Plan.    
  • Performs other duties and projects as assigned.

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