2 years prior experience in health plan environment
Bachelors degree or equivalent in Business Administration, Health Care or related field
445 Grant Avenue, San Francisco, CA 94108
The Compliance Specialist supports the efforts of the Compliance Officer to improve CCHP’s public presence and to provide excellent service to our existing and potential members, fellow employees, and business partners. With strong organizational skills, the Compliance Specialist assists the Compliance Officer in achieving the goals and objectives; identifies and resolves a variety of issues related to regulatory issues; maintains basic commercial regulatory files; develops and facilitates marketing materials; and prepares and submits Medicare/commercial marketing materials to federal and state regulators. This person has direct, daily contact with CCHP and Chinese Hospital managers, and other office staff persons.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Assists with regulatory filings into the Department of Managed Health Care (DMHC) and Centers for Medicare and Medicaid Services (CMS) protocols.
- Assist the Compliance Officer to monitor the day-to-day compliance
- Assist with conducting the (annual and quarterly) compliance risk assessment and assist with internal audit and monitoring activities.
- Develops Compliance Tracking on All Plan Letters (APLs) – Tracking Distribution, Potential FWA and Privacy Incidents Tracking Updates.
- Reviews policies & procedures, and business workflows / process as required or necessary – on State regulatory requirements (DMHC, DHCS).
- Submits / uploads filings in the DMHC portal.
- Collaborate with staff across various Departments on compliance projects/assignments and compliance operations related to State standards/regulations.
- Coordinates DMHC Plan Audits and works with business owners on compiling data / universes; facilitates submissions to Regulatory authorities (e.g., DMHC Surveys, etc.).
- Coordinate and/or manage the response to, and investigation of, privacy and security incidents and breaches of protected information; provide guidance or technical assistance and follow-up on mitigation and corrective action activities.
- Coordinate activities related to the implementation of compliance and privacy mandates (i.e., Federal and State laws and regulations including privacy and FWA risk assessments, audits, and the preparation of reports / metrics / dashboards.
- Extracts data, notices, as required, in DMHC Systems (e.g., Timely Access Reporting, etc.).
- Under the supervision of the Compliance Officer, research, analyze, and interpret laws, regulations, and contracts; develop, review, and update policies and procedures; conduct routine or focused reviews for adherence to State, and local (Covered California) regulatory and contractual requirements, as well as organizational needs. – DMHC & DHCS /State and Accreditation (NCQA).
- Assist organization with internal, external, third-party administration (TPA), and regulatory
- Provide guidance and assistance to CCHP departments in statutory and regulatory
- Assist the Compliance Officer with responding to compliance hotline reports, department calls, reports of non-compliance, or other contacts. Assist with strategizing potential solutions and their implementation, including but not limited to compliance review spot- checks, training sessions, or policy revisions.
- Assists with or leads the development of compliant (State/Covered California/DMHC/DHCS) marketing materials.
- Assists in performing presentations on educational trainings on Covered California/DMHC/DHCS requirements.
- Performs CAP follow-ups with business stakeholders.
- Perform ongoing compliance reviews to detect or confirm compliance
- Proactively cultivates and maintains strong, positive working
- Maintains confidentiality of all information related to members, medical staff, employees, integrity issues, audits, and as appropriate, other information.
- Assists with or leads the development of compliant marketing
- Assists in performing presentations on educational
- Stays knowledgeable and up to date with compliance of regulatory
- Follows established and newly implemented changes in departmental
- Review for accuracy and distributes the weekly Regulatory Calendar (filings and submissions) to CCHP’s impacted internal departments.
- Conducts delegation audits on Utilization Management (UM), Claims, Credentialing, Compliance Program, and other delegation-related functional areas. Reviews to determine compliance with related State and Federal rules, regulations, CCHP policies and procedures applicable to managed care/HMO processing. Delegation audits may include, but not limited to:
- Hill Physicians Medical Group
- Jade Health Care Medical Group
- Access Primary Care Medical Group
- Delta Dental
- Nations Hearing
- Daily access to CCHP’s Compliance Hotline Number and report any complaints received.
- Daily access to the CMS/HPMS Complaint Tracking Module (CTM) to verify receipt of any CTM cases for processing.
- Distribution of HPMS / CMS Memos to appropriate departments.
- Distribution of CMS Monthly Preclusion Listings to appropriate departments.
- Assist in taking meeting minutes during bi-monthly Compliance & Oversight Workgroup Sessions.
- Communicate with stakeholders and make recommendations on internal performance to implement delegation functional areas’ (e.g., claims, UM, Credentialing, etc.) handling best practices.
- Establish and maintain cooperative working relationships with internal staff and CCHP’s delegated entities.
- Maintains relevant knowledge necessary to perform essential job functions as a claim’s specialist.
- Complies with all CCHP internal policies and procedures, including those pertaining to ethics and integrity.
- Acts as a resource to the Compliance Department related to internal departments/functional areas (e.g., claims, UM, credentialing, grievance, appeals, and pharmacy data, etc.) and the MediTrac system and other CCHP internal systems as required.
- Learn, understand, and follow current and future regulatory (State and Federal) and industry standards on claims, UM, credentialing, appeals, grievances and other internal-related functional areas’ processing.
- Performs related work and other duties/projects as assigned.
- Bachelors degree or equivalent in Business Administration, Health Care or related field
- Two years prior experience in a health care environment
- Strong interpersonal and communication skills and ability to work effectively with a wide range of constituencies
- Excellent time management, organizing and coordinating skills
- Ability to make rational judgments on sensitive and confidential issues
- Ability to set and change priorities quickly and as the situation warrants
- Strong skills in Microsoft applications including MS Office: Word, Excel, PowerPoint, and Outlook
- Follows directions carefully and completely
- Works efficiently to maximize productivity
- Strong written and verbal skills
- Ability to read and write Chinese preferred
- Professional in manner and appearance
• Able to lift up to 30 pounds
• Use proper body mechanics when handling equipment
• Standing, walking and moving 50% of the day.
In our efforts to control the spread of COVID-19 and its variants, CCHP requires that its employees be fully vaccinated as of their start date. If you require a medical or religious accommodation we will engage in the interactive process with you. Proof of vaccination will be required prior to start. If we make you an offer and you are not yet vaccinated, we will accommodate a delay in start date. CCHP may also mandate that its employees receive vaccine boosters, and all accommodation laws will be followed.