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California - Hospital Health Plan Compliance Officer
Refer job# HZ1K25988
 
Hospital Health Plan Compliance Officer
The candidate will serve as the Hospital and Health Plan Compliance Officer, the Privacy Officer, and as a member of the Medical Center Leadership team. Will be responsible for the strategic development, implementation and evaluation of compliance management systems at the Medical Center, including contract hospitals, contract services, and other facilities. Analyze legal, regulatory, licensing and accreditation requirements and their impact on operations and oversee the development of compliance risk mitigation and corrective action plans. Ensure that controls are in place to guarantee privacy and security, to identify fraud, waste and abuse and to ensure that state and federal regulations are addressed. Collaborate with Medical Center leadership to ensure that operating procedures, systems and standards align with compliance requirements and controls and that staff is trained on these controls. Create and manage detailed audits of Health Plan and Hospital managed services. Develop strong collaborative leadership relationships with TPMG, external regulatory agencies and accreditation bodies, and use these relationships to manage risks and establish priorities and plans to address these risks. Ensure that the Medical Center has systems in place to achieve compliance by development of compliance management systems (such as training, policies, procedures, monitoring and auditing, among others) across all functions. Assist managers to adopt a culture of compliance in their daily operations. Oversee the development, implementation and evaluation of corrective action plans and responses to internally and externally identified compliance issues. Create and manage detailed on site audits of Health Plan and Hospital managed services. Co-lead the Medical Center Compliance Committee with TPMG partner and provide direction in establishing legislative and regulatory compliance strategy. Develop an audit plan and dashboard to communicate completion of corrective actions to senior leadership. Serve as the Privacy Officer and oversee systems to ensure the protection and security of member and patient health information. Ensure the integrity of the regional hotline process and conduct investigations to resolve compliance issues and complaints. In conjunction with Medical Center and Regional leaders, ensure that medical center service delivery changes meet requirements of state and federal regulators as well as billing requirements of Medicare and other federal coverage guidelines. Oversee medical center responses to external regulatory agencies such as CMS and the Federal Office of Civil Rights. Manage identified privacy breaches to ensure that all reports are filed, root cause analysis is performed and that controls are initiated to prevent further loss of protected health information. Provide oversight to the implementation of revenue cycle functions and ensure the remediation of Site of Service, Scope of Practice and billing/documentation issues. Responsible for identifying risk areas in the revenue cycle, including accurate coding and documentation. Work with Regional groups and HIM managers to implement compliance coding and documentation practices. Ensure that appropriately credentialed providers are supplying services to health plan and government sponsored groups. Lead education and implementation of new state and federal laws affecting care delivery and health plan operations.

The candidate should have a Bachelor's degree or equivalent in health care administration, business or public health administration, operations research, nursing, economics or other related field. Master's degree in Business, Health Care, Public Administration, J.D. or related field preferred. Must have 8-10 years of experience in hospital operations or multifaceted health care systems and multi-provider settings. Experience in revenue cycle, program development and strategic planning is required. Certified in Healthcare Compliance (CHC) or other equivalent compliance certification preferred. Should have knowledge of accreditation and licensing requirements including: The Joint Commission, NCQA, Knox Keene Act, CMS, Cal-OSHA, HIPAA, MEDI-Cal regulations and standards.
 
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