Job Description: Looking for a way to make an impact and help people?
Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Position Overview: The Senior Compliance Specialist is responsible for supporting the Corporate Compliance Manager and Corporate Compliance Officer in administering the organizationâ€™s Corporate Compliance Program. This position is responsible for implementing Compliance Program strategies and initiatives at the direction of the Compliance Manager and Compliance Officer. As a senior team member, this position is expected to provide leadership to the team under the direction of the Compliance Manager.
Lead investigations and oversee investigation team's work on compliance and fraud, waste and abuse (FWA) matters.
Develop compliance audit protocols and tools that will be used to conduct internal compliance audits of operational areas.
Lead internal compliance audits of operational areas.
Serve as a lead in working with Federal and State law enforcement agencies on all matters pertaining to noncompliance and FWA reporting, such as the NBI MEDIC, CMS, US Department of Justice, OIG, OHA, and the Medicaid Fraud Control Units.
Assist in developing the annual Compliance Workplan, which includes conducting a risk assessment and assessing the overall risk to the organization.
Assist in identifying and resolving areas of noncompliance.
Provide interpretation of rules and regulatory guidance for the organization.
Maintain current knowledge of changes in industry rules and regulations and assist in maintaining effective lines of communication with other departments to ensure these changes are disbursed appropriately.
Assists in the development, initiation, maintenance and updating of policies and procedures for the general operation of the Compliance Program. Assists with implementation of day-to-day operation of the Program.
Identifies potential areas of vulnerability and risk, develops and oversees corrective action and improvement plans for areas of noncompliance, and provides general guidance on how to avoid or deal with similar situations in the future.
Assists with the development and implementation of an effective compliance training program, including appropriate introductory training for new employees and ongoing training for all employees, managers and the Board of Directors.
Collaborates with other departments to direct compliance issues through appropriate channels for investigation and resolution.
Development of monthly, quarterly and annual reports to regulatory agencies as required.
Act as a liaison with external auditors as needed.
Assists Compliance Manager and Compliance Officer in responding to alleged violations of rules, regulations, policies, procedures and Code of Conduct and Ethical Standards.
Acts as an independent review and evaluation body to ensure that compliance issues and concerns are being appropriately evaluated, investigated, and resolved.
Monitors, and as necessary, coordinates compliance activities of other departments in order to remain aware of the status of all compliance activities related to the organization business and to identify trends.
Participates in maintaining an effective compliance communication program including promoting:
Use of the fraud and abuse hotline;
Heightened awareness of Code of Conduct and Ethical Standards;
Understanding of new and existing compliance issues and related policies and procedures.
Partners with the internal audit function of the organization to ensure effective audit and monitoring as it relates to the Compliance Program as needed.
Participates in oversight of delegated entities as determined by the Compliance Manager and Compliance Officer
Participates in compliance initiatives as needed
Performs day to day tasks of the compliance department as needed
Meet department and company performance and attendance expectations.
Perform other duties as assigned.
Work Experience: Minimum 4-6 years experience in the healthcare or health insurance industry with specific experience in Medicare and Medicaid compliance.
Education, Certificates, Licenses: Bachelor's degree in Business, Health Care Administration, Finance, Accounting or a related field. Maste's Degree preferred..
Knowledge: Excellent written and verbal communication skills. Ability to clearly communicate with co-workers. Basic math skills required, including percentages, ratios, graphing and spreadsheet skills. Strong research, analysis, organizational, and interpretative skills. Requires ability to define and prioritize problems and manage workload without direct supervision.Ability to gain a thorough understanding of PacificSource initiatives. Extensive knowledge of Medicare and Medicaid laws and regulations affecting our business. Respond timely to regulatory inquiries. Maintain a working liaison with CMS, and OHA. Keep PacificSource informed of new regulatory developments. Maintain sufficient reference materials to adequately research legal and regulatory issues. Participate as needed in the annual CMS applications process (if applicable) and the annual bid submission process as needed. Working knowledge of medical terminology. Ability to read and understand health contract and benefits language. Ability to work under time pressures, and to deal with emotional situations.
Building Customer Loyalty
Building Strategic Work Relationships
Contributing to Team Success
Planning and Organizing
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for customer service.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our many communities-internally and externally.
We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.