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
Responsible for the ongoing management of the Health Plan compliance policies, procedures and guidelines. This position supports the ongoing development, maintenance, review and assessment of PCHP’s compliance, evaluates changes in regulatory requirements and coordinates efforts to operationalize them across the Health Plan.
MINIMUM SPECIFICATIONS
Education
- Bachelor’s degree in Healthcare Administration, Business Administration or related field.
- Master’s degree in Healthcare Administration, Business Administration or related field is preferred.
Experience
- Five years of relevant professional experience as a healthcare compliance professional.
- Experience in designing and implementing organizational reporting processes and structures that enhance and encourage complete and accurate tracking, coordination and reporting of compliance activities and events.
Equivalent Education and/or Experience
- Seven (7) years of experience in a comparable position working in commercial or Marketplace (ACA) health insurance, or with a health insurance issuer offering Qualified Health Plans, may be considered in lieu of a degree.
Certification/Registration/Licensure
- HCCA Certified in Healthcare Compliance (CHC) required within two years from the date of entry into the position.
Required Tests for Placement
- None.
Skills or Special Abilities
- Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms.
- Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization.
- Excellent analytical and problem-solving skills.
- Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
- Ability to write clearly and succinctly with a high level of attention to detail.
- Proficient computer and Microsoft Office skills. Ability to learn new software programs.
- Knowledge of the Affordable Care Act (ACA), Federally-facilitated Marketplace and Qualified Health Plan (QHP) requirements, National Committee for Quality Assurance (NCQA), the Texas Insurance Code, and applicable federal regulations (45 CFR).
Responsibilities
Regulatory and Compliance:
- Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.
- Responsible for understanding and applying ACA/Marketplace regulations and requirements including 45 CFR Parts 153, 155, and 156, the Texas Insurance Code, TAC, and applicable CMS and Texas Department of Insurance (TDI) guidance.
- Prepares, coordinates, and tracks regulatory filings and submissions, including TDI form and rate filings (SERFF), QHP certification and recertification materials, and required CMS/Marketplace data submissions.
- Attends meetings hosted by regulatory agencies and tracks completion of compliance-related action items.
- Develop compliance committee agendas, presentations, and minutes.
Reporting and Monitoring:
- Maintains log and reporting of internal monitoring and compliance risks.
- Assists with the creation and implementation of the compliance risk assessment, and compliance monitoring and auditing work plan.
- Responsible for the ongoing tracking and monitoring of Health Plan compliance using data analytics.
- Assists with regulatory reporting related to fraud, waste, and abuse activities.
- Develops appropriate compliance reports, including dashboards, tracking logs and summary reports that communicate the status of the compliance program to leadership.
- Assigns and tracks completion of regulatory notices, rule changes, and guidance issued by the Centers for Medicare & Medicaid Services (CMS) and the Texas Department of Insurance (TDI).
Training and Education:
- Assists in developing and disseminating topic-specific education to Health Plan personnel based on identified risks or changes in law or regulation.
- Manages compliance training program including identifying gaps in training curriculum and reporting.
- Assists in the development and creation of internal Compliance related communications/newsletter.
Professional Accountability:
- Builds and maintains strong collaborative working relationships across PCHP’s functional areas including legal, contracting, provider relations, member relations, utilization management, quality monitoring and information systems.
- 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.
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.
