Compliance Advisor - Regulatory and Commercial

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flag_no USA
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Job Description:
  • Ensure that the company's internal departments are also compliant with state and federal regulatory requirements.
  • This is achieved by participating in the annual internal audits, working with internal staff to correct performance deficiencies, identifying internal areas for improvement, serving as the compliance contact with internal departments for member grievance oversight, pharmacy, provider network and member services for all State Programs product lines.
  • The Compliance Advisor will also provide regulatory guidance, legislation analysis and interpret Medi-Cal and other product line program requirements.
  • The Compliance Advisor will serve as the subject matter expert.
  • Additionally, this individual is a resource to internal staff on all product lines on compliance and regulatory matters and performs ad hoc internal audits as required, conducts oversight to correct performance deficiencies and as well as monitors Member Grievances and adherence to the AB1455 claims compliance standards for timeliness and appropriateness.

  • 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.
  • Preferred: Master's degree in Public Health or Health Care Management or other related area.
  • Four (4) years in a managed care setting.
  • Ability to manage multiple priorities and projects and meet deadlines; strong verbal and written communication skills.
  • Knowledgeable in commercial healthcare and health care compliance.
  • Highly developed presentation skills.
  • Knowledge of Medi-Cal Managed Care principles and/or government programs.
  • Working knowledge of DHCS, DMHC and CMS regulatory requirements are required, as well as highly developed analytical and critical thinking skills.
  • Excellent written and oral communication skills are essential.
  • Preferred: 2 years Medi-Cal and Medicare compliance, or provider services/contracting experience. One year staff training experience.