Mktpl Compliance Program Mgr
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
Childrens Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions. Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
JOB SUMMARY
The Marketplace Compliance Program Manager will be responsible for the daily oversight management of the Texas Federally Facilitated Health Insurance Exchange (Marketplace) product line to ensure compliance with applicable laws, regulations, and contractual requirements (Affordable Care Act (ACA), Code of Federal Regulations, CCIIO directives and Texas Department of Insurance regulations.) Specifically, this position will require in-depth knowledge of Marketplace eligibility, enrollment rules, operations, and marketing requirements. This position requires ensuring all operational aspects of the Company are following Marketplace regulations. The Marketplace Compliance Program Manager will be responsible for referring deficiencies within functional areas of the Company to Internal Audit to audit, monitor or validate adherence to regulations. This will include partnering with Internal Audit to ensure corrective action plans are issued, completed, and validated. This position will be responsible for providing leadership, guidance, and education company-wide to ensure compliance with policies, procedures, and deliverables related to Marketplace. Strong collaboration, communication, and interpersonal skills are required.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Timely and accurately communicate/disseminate compliance-related information to Operational areas, Leadership and Director of Federal Programs.
Analyze and evaluate information related to the healthcare regulatory environment (specifically related to the ACA and Marketplace) by monitoring appropriate state, federal, industry and association channels, and participating in workgroups as applicable.
Collaborate with internal operational areas on matters related to regulatory reporting, audits, and corrective action plans related to Marketplace.
Serve as liaison with the CCIIO Marketplace Account Manager
Manage deficiencies identify by CMS (CCIIO) and TDI.
Serve as liaison with Marketing and Growth's Product Management and Development Team.
Serve as liaison with Internal Audit function as it relates to ACA and Marketplace auditing, monitoring, and validating corrective action plans.
Monitor and assess compliance risks with state and federal regulations related to Marketplace and develop strategies to mitigate risks.
Serve as a resource for contractual and regulatory information including benefits.
Develop, implement, and manage Compliance policies and procedures for Marketplace and collaborate with the Policies and Procedures team to ensure accuracy of regulatory requirements and citations.
Develop training material and conduct internal / external stakeholder training sessions as necessary.
QUALIFICATIONS:
Education/Specialized Training/Licensure: Bachelor's degree in healthcare administration, compliance, business administration or related field required.
Masters degree in Healthcare Administration, Public Health, business or related field. Certification in Healthcare Compliance (CHC) or equivalent compliance credential preferred.
Work Experience (Years and Area):- 4-6 years of experience in healthcare compliance, with a focus on the ACA and Marketplace program and managed care required.
Experience working with regulatory agencies preferred.
Management Experience (Years and Area): Minimum of 1.5 years of management, supervisory experience, leading projects and conducting training.
Software Proficiencies: Standard Office Equipment