Job Summary

The Compliance Advisor III ensures that the Plan’s processes and operations are compliant with all state and federal regulatory requirements, including but not limited to, the Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), and the California Department of Managed Health Care (DMHC) requirements.  The Advisor III is responsible for developing and leading key initiatives related to regulatory deliverable submissions, regulatory reporting, regulatory analysis and implementation, regulatory audits, corrective action plans, regulator communications, and department processes/workflows.  The Advisor III leads cross-functional teams and workgroups and communicates updates, challenges, and risks to leadership through verbal and written reporting. The Advisor III serves as a Subject Matter Expert for the organization and assists business units in operational decision-making in accordance with regulatory requirements.

Duties

Serve as a lead Advisor within the department and conduct applicable departmental trainings.

Manage competing priorities and tight regulatory deadlines.

Research, analyze, and clearly communicate regulatory requirements/deliverables to applicable business units. Provide recommendations from a compliance perspective, as needed. Serve as a Subject Matter Expert for the rest of the organization and provide guidance on a wide array of compliance matters; assist business units in making decisions to ensure compliance with regulations. Prepare and conduct compliance-related trainings for internal business units and/or external entities.

Lead initiatives by developing and ensuring timely, thorough completion of cross-functional work plans and by leading workgroups.

Develop processes and specialized tools  to monitor compliance performance and support regulatory deliverables. Perform quality assurance checks on regulatory reports and written submissions by developing review tools.

Identify enterprise-wide issues and risks, recommend remediation plans, and oversight through to completion. Escalate risks to Compliance management and the Chief Compliance Officer.

Prepare the organization for regulatory audits by developing work plans, implementing audit readiness activities, identifying risks, and liaising with regulators.

Proactively drive continuous improvement by recommending compliance process improvement opportunities and implementing key Compliance Program activities. Support all Compliance units in implementing the Plan’s compliance program. Create workflows and drive efficiency within the Compliance department.

Provide written and verbal status reports to Compliance Leadership and Committees.

Duties Continued

As a Subject Matter Expert, develop and conduct training on unit processes, for lower-tiered positions. Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:
At least 5 years of healthcare related experience, with a minimum of 3 years in a managed care setting.

Experience to have working knowledge of Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services(CMS) and National Committee for Quality Assurance (NCQA) requirements.

Demonstrated experience developing and delivering training programs and making presentations.

Preferred: 

Supervisory experience and/or project management experience.

At least 2 years of regulatory change, policy, or risk management experience for a health plan or healthcare system.

Skills

Required:
Knowledge in health care compliance.

Must possess a strong understanding of Medi-Cal and Medicare laws and regulations and other state programs.

Highly developed analytical and critical thinking skills.

Excellent written and verbal communication skills are essential.

Ability to manage multiple priorities and projects and meet deadlines.

Ability to develop training programs and make presentations to unit and organization staff, including Leadership.

Persuasion Skills.

Working knowledge of DHCS, DMHC and CMS regulatory requirements.

Preferred:
Advanced skills in Excel, Visio, PowerPoint and SharePoint.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information