Position Purpose: This individual serves as the Compliance Officer for health plan/risk-bearing entities and has overall responsibility for enterprise-wide corporate compliance efforts and regulatory matters, including the appropriate management of outside resources as it pertains to compliance, regulatory compliance, legislative initiatives and other compliance matters that impact the organization. This position coordinates the annual review and revision of PHP’s Group Contracts including development of benefit contract that comply with legal and regulatory requirements. Ensures proper filing and maintenance of contracts, licenses, etc. with the Indiana Department of Insurance. Provides consultative services regarding contract interpretation and legal compliance.
- Leads the Corporate Compliance Program, functioning as an independent and objective person that reviews and evaluates compliance issues/concerns within the company. Performs ongoing compliance monitoring activities.
- Advises the company’s Executive Leadership team, Senior Leadership team, management team and staff on a variety of compliance issues.
- Researches unique compliance issues impacting the company through review of applicable statutes, regulations, regulatory notices, etc.
- Collaborates with and leads the Corporate Compliance Committee (Committee) to effectively incorporate the Program into the organization. Organizes the Committee, including developing agendas, reports and information as requested by the Committee, the CEO, CFO and/or the Board of Directors (Board), maintaining relevant files on same.
- Develops, initiates, maintains and revises policies, procedures and standards of conduct for the general operation of the Program and its related activities to prevent illegal, unethical, or improper conduct.
- Communicates and promotes the importance of compliance and the Program to senior management, the Committee and staff members.
- Coordinates the development of auditing and monitoring functions and investigations through examination of areas of risk and providing analysis of corporate responsibility complaints/issues.
- Identifies, assesses, advises, monitors and reports on risks associated with the company’s compliance operations, encompassing the risk of legal or regulatory sanctions, risk of financial loss, or loss to reputation the company may suffer as a result of failure to comply with applicable laws, regulations, codes of conduct and standards of good practice.
- On an annual basis, submits a report on the compliance activities and any needed changes in the Program to the CEO, CFO and Finance Committee of the Board of Directors.
- Responds to alleged regulatory violations or unethical or improper conduct, including those made through internal and external reporting processes (hotline), and investigates to ensure corrective action is taken. When necessary, collaborates with other departments to direct compliance issues to appropriate existing channels for investigation and resolution. Develops and oversees a system for uniform handling of such alleged violations.
- Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies, as required by applicable federal and/or state law.
- Identifies potential areas of compliance vulnerability and risk; develops and/or implements corrective action plans for the timely resolution of problematic issues; and provides general guidance on how to avoid or deal with similar situations in the future.
- Develops and/or maintains a mechanism to track access to protected health information, as defined by the Health Insurance Portability and Accountability Act, as required by applicable law.
- Oversees, directs and/or delivers the appropriate privacy training and orientation to all necessary personnel as applicable, including employees, committee members and/or board members.
- Develops and implements the ongoing compliance monitoring activities of all BAAs to mitigate risk to the extent reasonably possible. Participates in the implementation and ongoing compliance monitoring of all trading partner and business associate agreements, to ensure all compliance concerns, requirements and responsibilities are addressed.
- Maintains the breach incident log with respect to the potential unauthorized disclosure of protected health information and participates, with the applicable business leader, in the investigation of the same. Reports, annually or following a major incident, to the Office of Civil Rights within CMS, if it discovers a breach of unsecured protected health information.
- Tracks state and federal laws and regulations through the legislative process in the jurisdictions where PHP conducts business. Communicates pending legislation and regulatory changes to the appropriate person, department managers and/or Senior Team members.
- Leads annual Contract Committee in the establishment of revised Group Contract content and verbiage to incorporate company policies, benefit changes, etc., ensuring compliance with state and federal and regulatory requirements.
- Develops and conducts annual contract training with respect to the company’s fully-insured products, level-funded products and other, ancillary products.
- Assists all departments, specifically, Sales, Implementation Team, Customer Service, and Enrollment with eligibility determinations, interpretation of benefits and contractual language provisions.
- Files and maintains contracts, TPA licenses, agents license, forms, agreements, amendments, Small Group Certification, and other associated documents with regulatory bodies to comply with state and federal regulatory requirements.
- Provides consultative services for legal compliance, conferring with outside legal counsel as necessary.
- May assist in the periodic performance of compliance, privacy and security risk gap assessments.
Organizational Level: This position reports directly to the CFO and has no immediate direct reports as of this time. This position may have supervisory responsibility in the future.
- Keeping up-to-date on state and federal laws and regulations related to health care benefits and managed care.
- Providing proper interpretation of laws and regulations as they pertain to the compliance activities.
- Managing multiple priorities in a timely and effective manner.
- Identifying and managing effective information sources.
- Self-management, planning and prioritization of efforts.
- Maintaining a customer-focused attitude.
- Working against specific expectations, deadlines, and time requirements.
- Maintaining effective relationships with employees at all levels and with outside contacts.
- Maintaining high levels of confidentiality.
- Must be creative and have the ability to “think outside the box”.
- The ability to work with many different types of people in a mature and professional manner in problem solving and negotiation settings.
- Strong diplomatic skills.
- Maintaining accurate records and tracking devices.
- Creating and fostering improvement processes which cross departmental lines (e.g., operations, employer service, customer service, etc.).
- Detail oriented, organized, flexible.
A Bachelor’s Degree and five plus (5+) years of progressively responsible work experience or advanced degree (J.D.), with primary emphasis in regulatory compliance. Previous state or federal regulatory or managed care compliance experience is highly desired. State of Indiana Life and Health Insurance License preferred.
Critical Required Skills:
- Establishing strong relationships with internal and external constituents; has responsibility for relationships with key outside legal firms offering regulatory support.
- Strong knowledge of state and federal laws and regulations relating to an Indiana domiciled not-for-profit HMO, to provide examples to management and/or Senior Team of the laws and regulations that are relevant to PHP (e.g., Indiana’s Code on HMO’s and Insurance Companies, ERISA, COBRA, HIPAA and PPACA).
- Ability to work effectively with regulators, members of professional associations, company management and others.
- Thorough understanding of managed healthcare from a business perspective.
- Ability to research complex laws and regulations in order to provide interpretation of same.
- Self-directed team player.
- Effective computer skills (Word, Excel, Database, e-mail).
- Managerial skills necessary to plan, organize, integrate and administer programs that have a company-wide impact.
- Effective written and verbal communication skills necessary to elicit, and present technical information, participate in management-level discussions, and to deal effectively with employer groups, and brokers. In addition, must have a willingness to listen to the thoughts and ideas of others.
- Effective problem solving skills.
- Ability to be creative and find the market differentiators that set PHP apart from our competitors.
- The ability to manage multiple priorities within a demanding business environment.
- Ability to develop and sustain contacts and develop and implement business solutions.
- Commitment to the company and the achievement of its goals.
- Ability to effectively influence others and engage clients and coworkers on difficult issues.
- Ability to inspire confidence in and gain respect from superiors, peers….. click apply for full job details
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