Compliance Consultant III

Job Description

This individual contributor is primarily responsible for conducting company compliance activities under the guidance of more senior employees. Responsibilities include assisting with compliance reporting, compliance investigation, implementation of compliance efforts, and regulatory compliance through monitoring regulatory changes. This individual contributor also provides support on projects including assisting in development and coordination of plans and coordinating with stakeholders.

The Hotine Operations team is responsible for the triaging of all matters entered into the compliance case management system to the appropriate risk managment units (RMU) which includes but is not limite to;HR, Ethics and Compliance, Member Relations, etc.                                              

Essential Responsibilities                                                    

1. Triage approximately 20 cases per day/per service level agreement (SLA)

• Confirming geographic location
• Writing allegations statements
• Populating all triage fields (per protocol)
• Identifying priority level per guidance
• Escalating high risk matters (e.g. priority A etc.)
• Responding and completing requests for reassignment timley
• Assignment Directory Support
• Complete all mandatory training
• Attend team meetings

2. Case specific responsibilities include

• Identifying member type
• If reported matter meets escalation criteria (e.g.high-risk, involves compliance/HR/leadership)
• Support daily reconciliation
• Using analytical skills and good judgement, processes complaints through entering key data in case management (e.g., CaseTrack, ComplianceConnect). Applies detail-oriented skills to send communication to reporters in accordance with Standard Operating Procedures. Responsible for the timely processing of cases meeting escalation criteria.
• By reading and analyzing English text, and through established triage guidelines, assigns complaints to appropriate department for investigation, guided by the Assignment Directory or as directed by management, Centralized Investigations, Hotline Operations, and Reporting Unit personnel
• Maintains comprehensive knowledge of related organizational policies, guidelines, procedures, U.S. state and federal laws in all areas of Ethics and Compliance and other areas.
• Participates in projects and/or programs relating to but not limited to, Ethics and Compliance.
• Demonstrated problem-solving, decision-making and follow-through skills.
• Excellent oral and written communication skills.
• Must demonstrate an understanding of Ethics and Compliance.
• Demonstrated ability to identify key business issues
• Working knowledge of word processing, spreadsheet and database PC applications.

Essential Competency

• Business  and  compliance knowledge  –
• Ability to understand and evaluate ethics and compliance related situations, is comfortable fielding ethics questions from others, and builds the active application of ethical standards within the business.
• Ability to apply Compliance Program knowledge to relevant business(es) and/or function(s).
• Ability to understand ethics risk in the business; supports application of ethical standards across the business; models desired behavior and proactively reinforces importance of compliance and ethics initiatives.
• Demonstrates knowledge of the organization’s major business functions, organizational structure, and business model, as well as the external and internal factors influencing these elements; understands how changes in the business’s objectives and priorities translate into changes for the compliance and ethics department.                                     

Minimum Qualifications                                                        

• Bachelor’s degree  degree in Health Care Administration, Clinical, Law, Public Health, Business or related field and minimum three (3) years experience hotline/triage experience
• In lieu of degree, additional three (3) years experience for a total of six (6) required
• Masters degree credits an additional year of experience
• Two (2) years experience in health plan operations.
• One (1) year project management experience.
• Two (2) years experience working cross-functionally across departments, functions, or business lines.
• Two (2) years health care experience.                                                         

Additional Requirements                                          

Effetive lines of communication and responding promprtly to detected offenses

• Display an understanding of the Ethics & Compliance program and its relationship to the ecosystem, including processes and systems, as they relate to and interface with the Ethics & Compliance program.
• Ability to respond to reported and detected offenses in addition to providing assistance to operations in identification of compliance-related corrective action plans and identification of preventative actions to mitigate reoccurrence.
• Apply working knowledge of investigation trends, industry benchmarking, fraud schemes, regulations, system updates and training requirements to business specific situations.

Care delivery, revenue management and health plan –                                                                                                                                                                                 

• Able to apply understanding of new and existing compliance requirements and standards in the following (Fraud, Waste and Abuse (FWA), Privacy and Security (P&S), Quality of Care (QoC), Revenue Cycle, Conflict of Interest (COI), etc.).
• Apply understanding of basic revenue cycle functions, including coding, billing, documentation, and risk adjustment requirements and regulations.
• Apply understanding of health plan related risks and functions which impact the effectiveness of the compliance functions including provider contracting, access, network access in addition to Intake and analysis of new state regulations as well as some federal regulations.

Soft Skills

• Critical thinking to assess situations and data efficiently, creatively and accurately.
• Teamwork collaborating with colleagues from diverse backgrounds and valuing their strengths.
• Attention to detail with a keen eye for accuracy and making sure tasks are completed meticulously, with a commitment to high-quality work.
• Agility to pivot in a moment’s notice when unexpected circumstances arise.
• Adapting and responding to change. Adapts to changing circumstances; tolerates ambiguity; accepts new ideas and change initiatives; adapts interpersonal
• Style to suit different people or situations; shows an interest in new experiences.
• Time management to prioritize tasks effectively, manage their schedule meticulously, and meet operational deadlines to consistently perform repetitive work.
• Maintains a positive outlook at work; works productively and independently in a high-pressure environment; keeps emotions under control during difficult situations; handles criticism well and learns from it; balances the demands of a work life and a personal life.
• Focuses on customer needs and satisfaction; sets high standards for quality and quantity; monitors and maintains quality and productivity; works in a systematic, methodical and orderly way; consistently achieves goals.                                                           

Preferred Qualifications                                            

• One (1) year pharmacy experience to include pharmacy compliance, practice assessment, or regulatory affairs.
• Two (2) years medical coding experience.
• Two (2) years experience working in a clinical setting (e.g., hospital, medical center).
• Two (2) years experience in health plan compliance.
• Two (2) years experience in privacy and security compliance.
• Certified in Healthcare Compliance (CHC) or other equivalent compliance certification.
• Privacy & Security Compliance certification.

Benefits

• Transportation.
• Life insurance.
• Medical insurance.
• Solidarity association.
• Growth plans.
• Additional days off.

K3