Description
Duties:- The Compliance Advisor ensures that internal departments are compliant with all State Programs product lines program contractual, state and federal regulatory requirements.
- Participate in annual internal audits.
- Work with internal staff to correct performance deficiencies.
- Identify internal areas for improvement.
- Serve as the compliance contact with internal departments for member grievance oversight, pharmacy, provider network, and member services for all State Program product lines.
- Provide regulatory guidance, legislation analysis, and interpret product line program requirements for the company and its contracted entities.
- Act as a resource to internal staff on all product line compliance and regulatory matters.
- Perform ad hoc internal audits as required.
- Conduct oversight to correct performance deficiencies.
- Monitor member grievances and adherence to the claims compliance standards for timeliness & appropriateness.
Education/Experience:
- High School Diploma Required.
- Bachelor's degree in Business or Health Care Management.
- In lieu of a Bachelor's degree, at least 6 years progressive managed care, healthcare, healthcare compliance, and/or work experience will be considered.
- Master's degree in Public Health or Health Care Management or other related area preferred.
- At least four years in a managed care setting required.
- Experience in health care auditing and monitoring (preferable in Appeals, Grievances, Quality Improvement, UM and so forth) and developing audit tools.
- Knowledge in health care compliance.
- Ability to manage multiple priorities and projects and meet deadlines.
- Demonstrated experience developing and delivering training programs and making presentations.
- Knowledge of Managed Care principles and/or government programs.
- Working knowledge of DHCS, DMHC and CMS regulatory requirements.
- Highly developed analytical and critical thinking skills.
- Excellent written and oral communication skills are essential.
- 2 years Medi-Cal and Medicare compliance, or provider series/contracting experience.
- One year staff training experience.