Under general direction, to coordinate planning, development, implementation, and monitoring of an effective compliance and patient privacy program for the Santa Clara Valley Healthcare. Managed Care Plan:One position would be for the Valley Health Plan (VHP) Compliance Officer role. This candidate will be in charge of overseeing VHP’s compliance with the various managed care regulations, regulatory filings, delegation and pre-delegation audits, fraud, waste and abuse audits, etc. This position ... more details
Description
Under general direction, to coordinate planning, development, implementation, and monitoring of an effective compliance and patient privacy program for the Santa Clara Valley Healthcare.
Managed Care Plan: One position would be for the Valley Health Plan (VHP) Compliance Officer role. This candidate will be in charge of overseeing VHP’s compliance with the various managed care regulations, regulatory filings, delegation and pre-delegation audits, fraud, waste and abuse audits, etc. This position reports to the Chief Compliance Officer - Health System.
Typical Tasks
The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Each individual in the classification does not necessarily perform all duties listed.
Implements system-wide programs, policies, and procedures to ensure compliance with applicable federal and state laws and regulations, such those related to Medicare, Medi-Cal, managed care, commercial insurance, federal and state contracts and grants, and other applicable programs and funding sources;
Implements a system-wide patient privacy program by working closely with department leaders to ensure compliance with federal, state, and contract privacy laws and regulations, such as the Health Insurance Portability and Accountability Act, California Confidentiality of Medical Information Act, Lanterman Petris Short Act, 42 C.F.R. Part 2, etc.;
Directs activities for system-wide audits to investigate and monitor healthcare privacy, healthcare billing, and contract compliance with standards and procedures required by federal and state laws, including supervising the audit activities conducted by contracted consultants;
Develops, writes, and implements a code of conduct, policies, and procedures that establish standards for an organizational culture of compliance, privacy, and ethics, giving specific guidance to management, medical staff, and individual departments or employees, as appropriate;
Develops, implements, and provides orientation and ongoing educational programs via various communication platforms designed to specifically promote an understanding of compliance and privacy issues, laws, and regulations and the consequences of non-compliance throughout the County of Santa Clara Health System (CSCHS);
Maintains an awareness of compliance and privacy laws and regulations, keeping abreast of current changes that may affect healthcare systems through personal research, seminars, and peer contact;
Reviews and leads inquiries concerning billing and reports of noncompliance; reviews results of documentation compliance audits;
Participates in appropriate response, develops corrective action plans, and oversees compliance and privacy investigations, including maintaining the confidentiality of information reported by individuals in order to protect both the individual and the subject of the investigation;
Provides analysis of data sharing projects, including mapping data flows, analyzing data elements, interpreting federal and state privacy laws, and collaborating with the Information Security Office to ensure secure and appropriate release and storage of the Health System’s patient health information;
Implements and maintains a system for encouraging staff to report non-compliance and potential fraud, waste, and abuse without fear of retaliation;
Reviews complaints, concerns, or questions relative to compliance issues and provides consultative leadership and support to all entities as appropriate;
Ensures that internal controls throughout the system are sufficient to provide for accurate, complete, and compliant programs and processes;
Serves as a subject matter expert on relevant technology projects, providing expertise and guidance on the identification and mitigation of compliance and privacy risks, including potential False Claims Act violations, inaccurate documentation and billing, and breaches of federal and state privacy law;
Serves as the main point of contact for state and federal agencies conducting external audits and compliance and privacy investigations and leads the organization to ensure appropriate and timely responses;
Develops corrective action plans and oversees investigations, including maintaining the confidentiality of the investigation;
Organizes and leads Compliance Committees for the Health System Departments, including Hospitals and Clinics, Behavioral Health Services, Valley Health Plan, Custody Health, Public Health, and Emergency Medical Services, as well as represents Compliance on other County and Health System committees;
Prepares regular and timely reports to the Chief Compliance Officer, County Health System Leadership, and Compliance Committees on compliance and privacy issues and activities, including major findings, problems, and violations, and recommends remedial correction and prevention actions;
Promotes awareness and understanding of positive ethical and moral principles consistent with the mission, vision, and values of the organization and those required by federal and state law;
Interacts with all levels of management throughout the County of Santa Clara Health System;
Establishes guidelines and procedures for ongoing compliance review to identify risks and deficiencies, develop annual work plans, and recommend corrective action plans;
Supervises subordinate staff, including Program Managers and Compliance analysts;
May be assigned as a Disaster Service Worker (DSW), as required;*
Performs other related duties, as required.
Employment Standards
Sufficient education, training, and experience to demonstrate the ability to perform the above tasks, plus the possession and direct application of the following knowledge and abilities:
Training and Experience Note: The required knowledge and abilities are attained through possession of a Bachelor's degree, preferably in healthcare administration, finance, accounting, auditing, and/or a related field
AND
Five (5) years of professional level compliance and/or financial management experience, at least two (2) years of which must be in a hospital setting.
Special Requirements
Ability to travel to alternate locations in the course of work. If driving, possession of a valid California driver’s license prior to appointment and the ability to qualify for and maintain a County driver authorization.
*As a condition of employment, pursuant to California Government Code Sections 3100-3109 and Local Ordinance, all County of Santa Clara employees are designated Disaster Service Workers (DSWs), including extra help. A DSW is required to complete all assigned DSW related training, and in the event of an emergency, return to work as ordered.
Knowledge of:
Federal and state healthcare laws, regulations, and requirements for third-party billing (especially Medicare, Medi-Cal, and managed care);
Basic principles of hospital organization and administration;
Regulations and laws common to the operation of hospitals in California;
Accounting and auditing methods applicable to hospital and clinic operations;
Third-party audit reviews and risk assessments;
Planning and problem-solving methods;
Principles of supervision;
English usage, style, grammar, punctuation, and spelling;
Common computer systems and applications;
Ability to:
Administer, coordinate, and supervise the compliance program of a large, modern healthcare organization;
Keep abreast of current Medicare, Medi-Cal, and managed care regulations;
Explain and interpret compliance and privacy issues to other officials;
Identify compliance and privacy problems and devise procedural changes to resolve them;
Learn and apply the County of Santa Clara Health System’s policies, regulations, and administrative procedures in the context of the compliance program;
Communicate effectively, both orally and in writing, with people of diverse backgrounds and cultures;
Establish and maintain effective working relationships with those contacted in the course of work, at all levels, including colleagues, the public, and representatives of other agencies;
Work effectively as a member of a management team in a healthcare organization.
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