SWHRCIN VP Chf Rsk & Cmpl Off SWHR CIN at Southwestern Health Resources CIN in Pittston, Pennsylvania

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 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.

The VP Chief Risk & Compliance Officer oversees the corporate compliance, privacy and risk program, functioning as an independent and objective body that reviews and evaluates compliance issues/concerns within the organization. The position ensures the Board of Directors, management and employees are in compliance with the rules and regulations of regulatory agencies, that company policies and procedures are being followed, and that behavior in the organization meets the company's Standards of Conduct. This includes compliance with the requirements of all delegated functions for contracted payors. In addition, the compliance office is responsible for the integrity of all core business reconciliation efforts. The Compliance Officer will ensure the organization submissions and receipts reflect the accurate status of the Company 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 Compliance Officer will monitor and report on the integrity and accuracy of all reconciliations to ensure the achievement of the Company's objectives.

The Corporate 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 Company objectives are met

The VP Chief Compliance Officer acts as staff to the SEO and Board of Trustees' Corporate Compliance Committee by monitoring and reporting results of compliance / ethics efforts of the company and in providing guidance for the Board and senior management team on matters relating to compliance. The Corporate Compliance Officer, together with the Corporate Compliance Committee, is authorized to implement all necessary actions to ensure achievement of the objectives of an effective compliance and audit 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. Develops strategic plan for compliance, privacy and risk programs and manages day-to-day operations of the teams to support it.
• Develops and periodically reviews and updated Standards of Conduct to ensure continuing currency and relevance in providing guidance to management and employees.
• Assists the business units in developing strategy for the Company 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.
• 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. Risk Management, HR, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the corporate attorney as needed to resolve difficult legal compliance issues.
• Oversees management of compliance verification of downstream entities and independent contractors.
• Manages the special investigations unit (SIU) and internal audit teams; responds to alleged violation of rules, regulations, policies, procedures and Standard 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 status of compliance activities.
• Performs and/or oversees annual risk assessment to identify organizational risks. Based on risk assessment, works with leadership on creation of risk profile, metrics and risk tracking based on corrective actions.
• Provides reporting on a regular basis, and as directed or requested, to keep the Corporate Compliance Committee of the Board and senior management informed of the operation and progress of compliance efforts.
• Monitors key performance and risk indicators/metrics to assist with early identification of risk trends across various operational units.
• Institutes and maintains an effective compliance communication program for the organization, including promoting use of the Compliance Hotline and retaliation-free reporting; promotes awareness of Standards of Conduct and understanding of new and existing compliance issues and related polices/procedures.
• Partners with Human Resources and others as appropriate to develop an effective compliance training program for newly hired employees and annual refresher training for existing employees.
• Oversees coordination of external compliance audits from entities providing oversight, including but not limited to Contracted Payors, State Departments of Insurance, and CMS.

PROFESSIONAL EXPERIENCE/QUALIFICATIONS

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 Southwestern Health Resources' culture for action.

Education and/or Experience:

• Bachelor's Degree in healthcare or business-related field required.
• Master's Degree in healthcare or business-related field preferred.
• Minimum 10 years Management experience in healthcare, compliance or equivalent field required.
• Thorough knowledge of state and federal guidelines, accreditation bodies, participating provider agreements, HIPAA and Third-Party Administration (TPA) laws, credentialing regulation and prompt pay laws.
• Familiarity with operational, financial, analytics, quality assurance, audit and human resource procedures and Medicare Advantage regulations.

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