Full Job Description
Southwestern Health Resources was established in April 2016 as a unique partnership between the founding entities, UT Southwestern Medical Center, a public academic medical center, and Texas Health Resources, a private faith-based non-profit health system, based on a shared commitment to create a highly differentiated value proposition in both quality and total cost of care for consumers, purchasers, patients and physicians. A cornerstone of Southwestern Health Resources is a clinically integrated network of independent and employed physicians, including the employed faculty physicians of UT Southwestern, the employed physicians of Texas Health Physician Group, and independent community primary care and specialty care physicians. The integrated network builds on more than 50 years of collaboration between the two institutions to improve the health of North Texans.
Southwestern Health Resources includes 29 hospital locations and more than 5,000 physicians located throughout North Texas in its network. With over 650 points of access to care, this provides for higher value and allows patients to access services across a full continuum of medical needs. The network serves people across 16 counties in North Texas. SWHR coordinates care for more than 700,000 patients, aligned with commercial health care plans and Medicare programs, along with more than 13,000 Medicare beneficiaries enrolled in its Care N’ Care health plan. It also provides Population Health Services through clinical and quality data along with analytic services necessary to support the physician-driven clinical decisions.
The VP Compliance Officer serves in a leadership role within SWHR and oversees the SWHR Compliance Program, functioning as an independent and objective body that reviews and evaluates compliance issues/concerns within the organization. The position ensures the SWHR Board of Directors, management and employees are in compliance with the rules and regulations of regulatory agencies, that SWHR policies and procedures are being followed, and that behavior in the organization meets SWHR’s Code of Conduct and the Conflict of Interest policy. This includes compliance with the requirements of all delegated functions for contracted payors. In addition, the compliance department is responsible for the integrity of all core business reconciliation efforts. The VP Compliance Officer will ensure that SWHR’s submissions and receipts reflect the accurate status of the organization with respect to each payor for the following areas: risk adjustment, 5 Star Quality, claims payment, utilization status, analytics/reporting, and financial/Medicare premium payments. The VP Compliance Officer will monitor and report on the integrity and accuracy of all reconciliations to ensure the achievement of SWHR’s objectives.
The SWHR Compliance Office exists:
As a channel of communication to receive and direct compliance issues to appropriate resources for investigation and resolution;
As a final internal resource with which concerned parties may communicate after other formal channels and resources have been exhausted;
To provide consistency in the Compliance Program structure across the various subsidiaries; and
To assist the business units in assessing internal strengths, weaknesses and helping close gaps to ensure SWHR objectives are met.
The VP Compliance Officer acts as staff to the SEO and SWHR Board of Trustees’ Audit and Compliance Committee by monitoring and reporting results of compliance / ethics efforts of SWHR and in providing guidance for the SWHR Board, SWHR Audit and Compliance Committee and the senior management team on matters relating to compliance. The VP Compliance Officer, together with the SWHR Audit and Compliance Committee, is authorized to implement all necessary actions to ensure achievement of the objectives of an effective compliance program.
RESPONSIBILITIES AND DUTIES
The VP Compliance Officer has the following duties and responsibilities:
Develops initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct. Manages day-to-day operation of the Compliance Program.
Periodically reviews and updates the Code of Conduct and the Conflict of Interest policy to ensure continuing currency and relevance in providing guidance to Board and Committee members, management and employees.
Assists the business units in developing strategies for the organization to reconcile all capitation payments, premium revenue, internal and external claims payments, clinical/utilization data and member eligibility. Ensures the respective units have processes in place to internally monitor and report payment inaccuracies.
Advises and collaborates on the development and revision of policies and procedures for the general operation of the business units and related activities to ensure accurate financial performance by each business unit/department and the payors contracted with the organization.
Develops and oversees the implementation, development, and maintenance of operational controls, and programs for reconciliation and integrity of the reporting of SWHR data.
Acts as an independent review and evaluation body to ensure that compliance issues / concerns within the organization are being appropriately evaluated, investigated and resolved. Collaborates with other departments (e.g. HR, Internal Audit, Physician Network, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the Office of the Chief Legal Officer of SWHR as needed to resolve legal compliance issues.
Responds to alleged violations of rules, regulations, policies, procedures, and the Code of Conduct by evaluating or recommending the initiation of investigative procedures. Develops and oversees a system for uniform handling of such violations.
Monitors, and as necessary coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.
Identifies potential areas of compliance vulnerability and risk; develops / implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in the future.
Provides reports on a regular basis, and as directed or requested, to keep the SWHR Audit and Compliance Committee and senior management informed of the operation and progress of compliance efforts.
Monitors key performance and risk indicators/metrics to assist with the early identification of risk trends across various operational units.
Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline; (b) heightened awareness of the Code of Conduct and the Conflict of Interest policy, and (c) understanding of new and existing compliance issues and related policies and procedures.
Works with Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees as well as ongoing training for all employees.
Participates and coordinates the external compliance audits from entities providing oversight including but not limited to, contracted payors, State Departments of Insurance (e.g. TDI), and CMS.
Individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This role requires the ability to solve problems, think outside-the-box, and be resourceful; must be result-oriented, a quick learner, collaborative, respectful, an effective communicator, and a self-starter. The requirements listed below are representative of the knowledge, skill, and/or ability required to build South Western Health Resources’s culture for action.
Education and/or Experience:
Juris Doctor degree preferred.
Master’s Degree in healthcare or business-related field desired.
Minimum 10 years management experience in healthcare compliance or equivalent field required.
Significant experience with effectively making presentations to Boards, Committees and senior leadership is required.
Familiarity with operational, financial, analytics, quality assurance, audit and human resource procedures and Medicare Advantage regulations is a must.
Thorough knowledge of state and federal regulations and guidelines, accreditation bodies, participating provider agreements, HIPAA and Third-Party Administration (TPA) laws, credentialing regulation and prompt pay laws required.