The posting
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Job Description:
Position Summary: fulfill Aspire’s compliance commitment by planning, designing, implementing and refining the Compliance Program. This involves developing standards, coordinating compliance training and education, conducting or arranging both internal and external regulatory audits, identifying compliance issues and trends, investigating and resolving compliance complaints and promoting awareness and understanding of the positive ethical and moral practices consistent with the mission and values of Aspire and those required by state and federal law.
Duties & Responsibilities:
- Demonstrate strong understanding of the health insurance industry and serve as a primary contact with CMS and the Department of Managed Health Care (DMHC) in California.
- Maintain communication with the CMS Regional Office regarding adjudication of Medicare complaints (CTMs), management of corrective action plans (CAPs), implementation of new federal regulations, and approval of marketing materials and plan documents.
- Maintain communication with the DMHC Office of Plan Licensing regarding implementation of any new state regulation over commercial products.
- Monitor and keep current with Medicare Advantage, California commercial, and National Committee for Quality Assurance (NCQA) contractual and statutory obligations.
- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
- Develop and launch training and education concerning Aspire’s compliance responsibilities.
- Develop and submit state and federal filings/certifications in CMS’ Health Plan Management System (HPMS) and/or the DMHC portal.
- Create risk assessments and work plans to ensure compliance program effectiveness.
- Monitor key performance indicators (KPIs) and deploy internal audits for the purpose of detecting non-compliance with applicable laws and compliance program requirements.
- Manage the development, review, revision and regulatory submission of departmental policies and procedures.
- Coordinate Fraud, Waste and Abuse (FWA) investigations with Aspire’s Special Investigations Unit (SIU).
- Enforce FWA, Privacy/Security and compliance standards and investigate possible violations.
- Initiate HIPAA breach incident reporting to the Office of Civil Right (OCR) and state regulators, if necessary.
- If any non-compliance is detected, ensure that it is investigated, a corrective action plan is developed and carried out, and that compliance is achieved and sustained.
- Prepare compliance reports to the Board of Directors and Executive Management to ensure they remain informed of compliance issues and developments.
- Monitor the effectiveness of the Compliance Program on a regular basis, including a comprehensive review conducted at least annually. Prepare annual budget for compliance activities.
- Prepare operational plans based upon budget projections.
Education/Experience/Licensure:
- A minimum of 7 years’ experience working in health plans is required; 3-5 years management experience.
- Advanced college degree with a focus on law, business law, or health administration is strongly preferred.
- CHC (Certified in Healthcare Compliance), CIA (Certification in Internal Audit), or equivalent preferred or the ability to obtain necessary certification within 6 months.
- Relevant work experience may be substituted for educational requirements.
- A strong background in Internal Audit techniques, practices and theories.
- Thorough understanding of effective internal audit guidelines and reporting requirements.
- Knowledge of the Knox-Keene Act and its requirements is strongly preferred.
- A strong background in HIPAA and FWA practices and regulations.
- Strong knowledge of California Commercial health plans, Medicare Advantage/Part D, and NCQA guidelines, with demonstrated experience in managed care contracting and state/federal and accrediting body reporting requirements.
- Knowledge of Risk Adjustment Data Validation (RADV) audits is strongly preferred.
- Ability to collaborate with all levels of management and staff.
- Collaborate with departmental stakeholders to conduct oversight of First Tier, Downstream and Related Entities.
- Able to successfully manage multiple priorities and assignments.
- Able to perform other compliance duties, as assigned.
- Outstanding communication skills, both written and verbal; interpersonal skills in relating with others.
- Excellent skills in using Microsoft Office products are required.
About Aspire Health
In collaboration with Montage Health and Salinas Valley Health, Aspire Health is committed to inspiring every individual to live life to the fullest. As a local, nonprofit healthcare organization rooted in Monterey County, we bring together people, providers, employers, health plans, and community partners to improve health, promote wellness, and ensure access to high-quality care. Our mission is to improve the health of all by creating meaningful connections, supporting healthier communities, and helping people thrive at every stage of life.
Through innovative healthcare solutions, personalized support, and strong community partnerships, Aspire Health helps individuals and families navigate their healthcare journey with confidence. Whether connecting people to coverage, coordinating care, addressing barriers to health, or supporting local employers and providers, we are dedicated to building a healthier future for Monterey County, one person, one family, and one community at a time.
Location: Based in Monterey, CA, with hybrid or remote work arrangements potentially available for qualified candidates.
Aspire Health is an equal opportunity employer.
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Assigned Work Hours:
Full time (exempt)
Position Type:
Regular
