Senior Compliance Specialist
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
• Children’s 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 Senior Compliance Specialist works under the direction of the Director of Compliance to provide information, analysis, and recommendations for compliance activities supporting Community's adherence to all regulatory, legal, and contractual requirements. The role also serves to research information and to work with operations on reasonable and logical solutions to accomplish compliance. The Senior Compliance Specialist is responsible for conducting internal monitoring as part of the Compliance program.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Facilitates action and dialogue between business owners to plan and execute regulatory requirements; and develop corrective action plans. Leads/participates in controls and compliance related projects (e.g., regulatory-based projects, risk identification, monitoring of financial penalties.) to minimize liquidated damages impacts to the extent practicable while remaining compliant with all applicable regulatory requirements.
Assist with the execution of fieldwork to include working directly with business owners to onboard reporting. This includes thoroughly reviewing reporting requirements, ensuring business leads execute implementation of new reporting requirements timely, and triaging questions regarding reports, to and from the regulators.
Develops a strong relationship with business owners to understand business processes and issues contributing to compliance issues to be able to effectively communicate the issues to leadership. Based on the results of these analyses, makes decisions on next steps. Reviews and prepares applicable documentation with minimal supervisory review for management and committee review. Documents may include, but not limited to, audit and tracking tools, control matrices, flowcharts, narratives, testing summaries, presentations, etc.
Participates as an independent contributor with little supervision; or as an active team member depending on the situation. Assists in bringing a broad range of compliance activities to successful completion. Produces work that is highly accurate, demonstrates attention to detail, and reflects well on the organization regarding written communications, compliance deliverables, etc.
Researches and analyzes current and emerging state and federal regulations, to provide guidance to business owners and departmental inquiries. Assesses cross-department management action plans in response to trend reports to ensure 100% compliance to all federal, state, and local laws. Provides training on regulatory or reporting updates to business owners on all areas of the compliance program. Performs assessment and follow-up on corrective action plans to determine effectiveness of actions pursued. As necessary, works with business owners to re-evaluate solutions if trends are not responding to previous actions.
Independently evaluates regulatory correspondence for appropriate triage and resolution. Communicates effectively with regulatory contacts, in the absence of Compliance & Risk Management leadership; attends committee meetings as needed and presents related reports or status updates. Covers calls as a compliance team member. Ensures that topics and action items discussed on calls are disseminated to internal stakeholders.
Helps to manage, plan, facilitate and staff the monthly Regulatory and Compliance Committee meetings including agenda planning, and reporting, with the guidance of the Director of Compliance, evaluates departmental processes for gaps/deficiencies. Evaluations will impact remediation efforts of business owners, scope of monitoring projects, reporting of issues to executive management and the Audit Committee.
Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans and other duties as assigned.
Reports to Position Title:Director Compliance State Program
QUALIFICATIONS:
Education/Specialized Training/Licensure:BA/BS in Healthcare Administration, Business Administration, or related field required.
4 years of experience in conducting audits and client facing activities may substitute for the degree requirement required
CHC, CCEP or CHPC certification preferred.
Work Experience (Years and Area):Minimum 4 years in the healthcare payor industry (Medicare/Medicaid), at a team lead/supervisor level, conducting audits and client facing activities.
Management Experience (Years and Area):N/A
Software Proficiencies: Microsoft Office (Word, Excel, PowerPoint, MS Teams, MS Sharepoint, Outlook)
Other:Understanding of Texas health insurance market and regulators such as TDI, HHSC, and CMS.