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Job Summary
This position is responsible for monitoring and overseeing the corporation’s, its subsidiaries, and its subcontractors compliance with federal, state and local regulatory and contractual obligations applicable to NM Medicaid and chip programs. This position oversees administration of the compliance program, including identifying potential areas of non-compliance by conducting investigations and/or performing compliance reviews, performing risk assessments, consulting with the business owners to remediate identified issues of non-compliance and reporting compliance metrics, preparing reports and/or disclosures to the board of directors, it committees, compliance committees and governmental agencies, and providing advice and guidance to operational areas regarding proper policies and procedures.
Job Responsibilities
• Provide planning, implementation and monitoring of activities associated with regulatory and contractual requirements for government programs. Develop process and procedure flows to ensure that reports, or specific obligations mandated from government agencies are implemented by the appropriate business areas. Coordinate the development of policies and procedures designed to maintain the accuracy and timeliness of completing contractual requirements. Ensure that the process of filing certification and attestations with the government is documented.
• Analyze and oversee supportive data to prevent regulatory sanctions, foster regulatory relationships and integrate operations with regulatory requirements. This includes coordination with internal departments, i.e. Internal Audit, Special Investigations Department, Legal, as well as subcontractors to align for appropriate information collection and reporting. Work closely with Internal Audit and other business areas for the resolution of audit findings or other issues raised by the Government regarding non-compliance.
• Review and interpret regulatory documentation for adherence to standard criteria. Develop programs to accommodate corporate goals. Review filings made to government agencies.
• Perform reviews of various aspects of government programs and conduct investigations where necessary including investigations of any subcontractor, first tier entities, downstream entities and/or related entities.
• Prepare reports based on the completion of compliance reviews and investigations related to government programs.
• Design, implement, and monitor program projects and initiatives in all aspects of Government Programs.
• Serve as a resource on problematic issues generated from changing laws, regulations and guidance to maintain consistent/accurate interpretations.
• Participate in enterprise-wide initiatives and task forces in order to provide advice and guidance on compliance with government programs requirements.
• Manage reporting system to ensure that all contacts regarding possible non-compliance or misconduct involving a government program are properly logged, investigated and resolved including making recommendations to the Compliance Officer regarding whether disclosure should be made to the government, corrective actions, and disciplinary actions. Maintain documentation for each report of potential fraud, waste and abuse received through any reporting method (i.e. hotline, mail, in-person, exit questionnaires) which describes the initial report of non-compliance, the investigation, the results of the investigation, and all corrective actions and/or disciplinary action(s) taken as a result of the investigation.
• Direct research on laws and regulations to support investigative reviews related to government programs.
• Direct applicable audit functions to support investigative reviews of any potential wrongdoing related to government programs.
• Develop Corrective Action Plans and make recommendations regarding new policies and procedures based on risk assessments, compliance reviews, investigations or weaknesses.
• Identify needs and opportunities for communication to management regarding compliance issues and policies.
• Identify areas for training and communication to employees directly or indirectly related to Government Programs regarding compliance.
• Monitor Fraud, Waste and Abuse program as required under CMS guidelines and Medicaid contract including coordination with Special Investigations Department and Internal Audit
• Provide briefings on government programs requirements to the Compliance Officer, to the Board and its Committees and Compliance committees.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company related business.
• Maintain effective communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
Required Job Qualifications:
* Bachelor’s Degree
* 8 years of auditing or investigative experience with a focus in government or compliance reviews.
* 5 years of managerial experience.
* Management and negotiation skills.
* Effective verbal and written communication skills.
Preferred Job Qualifications:
* 3-5 years of experience in a government programs health plan
*This is a hybrid role based in Albuquerque, NM and will sit in this office 3 days/week*
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HCSC Employment Statement:
HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
