POSITION SUMMARY
Under the supervision of the Chief Compliance and Health Equity Officer (CO) help ensure Community Health Group (“CHG”) complies with applicable federal, State, and local laws, regulations, and contract requirements through the creation and maintenance of an effective compliance program. This position serves as an investigator in the Special Investigations Unit.
COMPLIANCE WITH REQUIREMENTS
Comply with all applicable legal and compliance requirements, including but not limited to federal and State laws and regulations; privacy, confidentiality, and information security mandates; and CHG policies and procedures.
POSITION DUTIES
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Assist in the management of day-to-day operations of the Compliance Department.
- Contribute to the achievement of established Department goals and objectives and adhere to Department policies, procedures, and standards.
- Organize and maintain inventory of Compliance Department policies and procedures.
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Maintain a strong working knowledge of all applicable legal, regulatory, contractual, and accreditation requirements. Update job knowledge by participating in educational opportunities and reading professional publications.
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Perform special projects as requested.
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Discharge other duties as may be required in the course of business or as may be assigned by the CO.
Fraud Waste and Abuse Prevention and Detection Program (“FWA Program”)
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Serve as the SIU investigator.
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Under the direction of the CO, timely and comprehensively coordinate, monitor, and perform duties related to CHG’s FWA Program, including investigations, CAPs, education and training, and FWA Program development and risk management.
- Case Investigation: Evaluate, investigate, and resolve high-volume claims flagged for potential fraud (e.g., staged accidents, exaggerated medical injuries, arson).
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Evidence Gathering: Utilize public records, database searches, forensic tools, and field interviews with witnesses and claimants to gather evidence.
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Regulatory Compliance: Ensure all investigations adhere to California Department of Insurance regulations, Centers for Medicare & Medicaid (CMS), Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC) and other statutory requirements.
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Reporting and Documentation: Prepare detailed, objective, and comprehensive reports summarizing investigation findings for claims, legal, and law enforcement partners.
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Liaison and Training: Act as a subject matter expert on fraud, maintaining relationships with law enforcement and providing fraud awareness training to internal teams.
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Surveillance (If applicable): Conduct field surveillance to verify claims.
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Work with all CHG stakeholders to ensure the FWA Program requirements are accomplished in a timely, comprehensive, and effective manner, in accordance with CHG’s FWA policies and procedures, and in compliance with applicable State and federal regulatory, legal, and contractual requirements.
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Track and provide FWA Program reports on a regular basis, and as directed or requested.
Privacy Compliance Program
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Under the direction of the CO, timely and comprehensively coordinate and assist in the implementation and maintenance of the Compliance Program.
- Assist in the investigation of potential privacy incidents.
- Assist with and track responses to regulatory inquiries, investigations, data, and other requests.
- Under the direction of the CO assist with the coordination of the CMS, DMHC and DHCS audits.
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Serve as one of CHG’s Compliance Department liaisons with regulatory agencies, including for responses to State inquiries, audits, and report requests. Assist in the drafting and review of responses to regulatory agencies.
ADMINISTRATION AND MANAGEMENT
Education
- Bachelor’s Degree in compliance, health policy, health administration, legal or regulatory affairs, or other related disciplines strongly preferred. Managed health care management experience may be considered in lieu of academic training.
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Education and Certification in Healthcare Compliance (“CHC”) or risk management or fraud examination is preferred.
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Certification in Medical Coding is preferred.
Experience/Skills
- Minimum four or more years’ experience in auditing, compliance, legislative affairs, regulatory affairs, or public policy analysis preferred.
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Four or more years in a managed care setting is strongly preferred.
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Customer service skills with the ability to interact professionally and effectively with all stakeholders.
- Excellent written and verbal communication skills and detail oriented.
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Understanding of NCQA, State/Federal legislative and regulatory processes, health plan operations, and the relationships between departments and functional areas.
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Hands on compliance implementation experience with health care industry statutory, regulatory, and/or accreditation requirements, preferably with CMS, DMHC, and/or DHCS.
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Demonstrated ability to utilize and apply internal compliance auditing principles, practices, and techniques.
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Strong abilities to organize and prioritize work effectively; manage projects; and apply established policies procedures and guidelines for problem-solving and decision making.
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Ability to maintain confidentiality and comply with applicable privacy and confidentiality requirements.
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Intermediate to advanced level proficiency with MS Office applications (Word, Excel, PowerPoint, Access), expertise with graphics and presentation software.
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Strong attention to detail.
Physical Requirements
- Prolonged periods of sitting.
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Some travel, including driving within the County of San Diego.
The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified
All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.
