The posting
Special Note: Strong candidates will have experience with Affordable Care Act ACA-related regulations, compliance requirements, reporting, or administration rather than simply having general healthcare experience.
Work schedule: Hybrid / Full-time Days; 8 a.m. until 4 p.m., Monday through Friday
PRIMARY PURPOSE
Parkland Community Health Plan’s (PCHP’s) Program Manager, ACA, is responsible for ensuring that PCHP complies with all applicable laws, regulations, and internal policies. Key responsibilities include developing and implementing compliance policies and procedures, conducting regular internal audits, ensuring employee training on compliance, managing relationships with regulatory agencies and leading compliance investigations. The role requires a strong background in health care compliance management, excellent attention to detail, and the ability to effectively communicate and educate team members on compliance requirements. The Program Manager, ACA ensures product and services are being tested for compliance with program regulations, insurance regulations, and regulatory requirements for business entities.
MINIMUM SPECIFICATIONS
Education
- Bachelor’s degree in business, public health, health policy, health care administration, legal studies or a related field, required
- Master’s degree in business, public health, health policy, health care administration, legal studies and/or another advanced degree in a related field, preferred
Experience
- 5 + years of directly related experience in managed care operations, health care compliance, and related legislative and regulatory research or an equivalent combination of education and related experience.
- Experience in the administration, management and oversight of ACA products and plans, with a focus on contract compliance, audits, corrective action plans and risk management.
- Experience with developing, implementing or administering compliance education and training to ensure adherence to regulatory requirements, specific to the ACA.
- Experience and demonstrated knowledge of relevant federal and state government regulations, guidelines and reporting requirements for CMS and TDI, regarding the administration and oversight of ACA products and plans.
Equivalent Education and/or Experience
- Strong legal/regulatory knowledge, risk management, policy development, investigative skills, and/or experience detecting fraud, waste and abuse, and experience with effective stakeholder collaboration and communication.
Certification/Registration/Licensure (Preferred)
- Certified in Healthcare Compliance (CHC) from the Health Care Compliance Association (HCCA),
- Certified Compliance and Ethics Professional (CCEP), from the Society of Corporate Compliance and Ethics (SCCE),
- Certified Professional Compliance Officer (CPCO) from the American Association of Procedural Coders (AAPC).
Required Tests for Placement
- None.
Skills or Special Abilities
- Strong analytical, critical thinking and problem-solving skills with meticulous attention to detail, interpreting complex regulatory language to identify risks, assess cross functional impacts and provide recommendations for resolution
- Strong communication skills demonstrating effective, professional interaction with federal and state regulatory agencies in a managed care or insurance environment
- Ability to collaborate cross functionally with diverse stakeholders throughout the organization Ability to lead and work independently, and as part of a team
- Skilled at developing and implementing corrective action plans
- Ability to effectively manage multiple deadlines and time constraints
- High proficiency in Microsoft Word, Excel, and PowerPoint
Responsibilities
- Maintain and track applicable federal and state laws, regulations, and sub regulatory guidance affecting the ACA product line — along with contract documentation, amendments, and key compliance measures.
- Provide compliance oversight of sales, marketing, agent/broker activities, quality, provider and network management (including network adequacy standards), clinical operations, utilization management, claims (including prompt pay requirements), premium billing, enrollment and eligibility, and member services to ensure compliance with ACA, CMS, and Texas Department of Insurance regulations and requirements.
- Manage and support the annual QHP certification, recertification, and renewal cycle, including CMS plan and benefit data submissions, essential health benefits, and actuarial value reviews, and coordination of TDI form and rate filings.
- Coordinate and monitor required federal and state regulatory reporting and data submissions for the ACA product line, including medical loss ratio (MLR) reporting, risk adjustment, data submissions, transparency in coverage reporting, and other CMS and TDI reports.
- Develop policies, procedures, and a consistent, reliable process to engage all stakeholders in an annual review of all policies to ensure compliance with federal and state program regulations.
- Provide guidance to various departments regarding compliance issues and implementation of new and changing ACA requirements, including annual benefit and payment parameter changes, QHP certification standards, and state regulatory and contract language.
- Conduct compliance audits and monitoring of ACA operations and delegated entities; develop and implement corrective action plans; support readiness for CMS program audits, HHS risk adjustment data validation (HHS-RADV) audits, and TDI market conduct examinations and complaint inquiries.
- Perform risk assessments and report emerging trends, deficiencies and variances; report findings to other departments and teams as appropriate.
- Review member-facing materials and marketing content for the ACA product line — including Summaries of Benefits and Coverage (SBCs), evidence of coverage, renewal and discontinuation notices, and required member notices — for compliance with federal and state requirements.
- Monitor complaint, appeal, and external/independent review organization (IRO) processes for the ACA product line to ensure compliance with federal and state requirements and timeframes.
- Support oversight of delegated vendors and first-tier, downstream, and related entities performing ACA functions, including due diligence, monitoring, and corrective action follow-up.
- Provide required ACA/Marketplace-specific compliance training — as appropriate, for existing and new employees and as required for non-employees and delegated entities.
- Provide mentoring and guidance within the department, as appropriate.
Professional Accountability
- Promotes and supports a culturally welcoming and inclusive work environment.
- Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
- Adheres to organizational policies, procedures, and guidelines
- Completes assigned training, self-appraisal, and annual health requirements timely.
- Adheres to hybrid work schedule requirements.
- Attends required meetings and town halls.
- Recognizes and communicates ethical and legal concerns through the established channels of communication.
- Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information
- Maintains confidentiality at all times.
- Performs other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.
Job Accountabilities
- Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
- Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
- Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.
