Job Abstract

The Compliance Advisor II ensures L.A. Care business units are compliant with all Product Lines' contractual, state and federal regulatory, and accreditation requirements. The Compliance Advisor develops regulatory submissions, reports, agendas and communications to the Internal Compliance Committee and the Compliance and Quality Committee of the Board of Governors and provides support for the management of external state and federal regulatory audits. The Compliance Advisor prepares executive summaries and reports, develops and conducts training activities for subordinates, peers and L.A. Care business units and participates in interdisciplinary/cross-functional teams.

The Compliance Advisor may investigate, assist with coordination and management of teams and workgroups, project documentation and workflows, draft and complete presentations, auditing and monitoring of performance standards, and other duties as assigned. Although the Compliance Advisor's primary responsibility is providing support and for the Regulatory Compliance unit, the Advisor also advises and supports the Manager, Director, and Chief Compliance Officer on other duties as assigned to support the mission and responsibilities of the Compliance Department and to support the business operations of L.A. Care Health Plan.

Analyze and interpret contractual, state and federal regulatory, and accreditation requirements.

Participate in and conduct compliance functions, including, but not limited to, developing compliance tools and validating implementation of new requirements and corrective action plans.

Work with internal business units to prepare reports for distribution to internal Committees and external entities.

Facilitate cross-functional teams including internal business units and/or external entities to correct performance deficiencies.

Prepare and conduct trainings for internal business units and/or external entities.

Review, approve and suggest revisions on policies and procedures, member/provider materials, compliance work plans, etc., as well as submit to regulatory entities for approval.

Work with internal business units to identify gaps, develop and implement corrective action plans and facilitate monitoring activities to ensure compliance with regulatory requirements. 

Review internal and external inquiries and collaborate with all levels of organizational management, business units and our Delegates to ensure timely, accurate, and complete submissions. This includes self-disclosures of non-compliance issues to the regulators.

Develop, maintain, and monitor Internal Compliance Committee (ICC) Charter, Compliance Program and  key performance indicators. Responsible for the development of Board/committee write-ups to be presented at the Compliance & Quality (C&Q) and Internal Compliance Committee (ICC) meetings.

Perform other duties as assigned.

Required:

At least 3 years of experience in a managed care setting.

Experience in health care auditing and monitoring (preferably in Appeals, Grievances, Quality Improvement, Utilization Management (UM) and so forth) and developing audit tools.

Demonstrated experience developing and delivering training programs and making presentations.

Preferred:

2 years of Medi-Cal, Medicare or commercial product compliance. Regulatory change management and risk management experience and/or business continuity experience in a health plan or hospital setting preferred. 

Required:
Excellent written and verbal communication skills.

Knowledge in health care compliance.

 
Ability to manage multiple priorities and projects and meet deadlines. 

Knowledge of Medi-Cal Managed Care principles and/or government programs.

Persuasion Skills: 1. Ensuring organizational compliance with all state and federal Medi-Cal Program requirements reduces L.A. Care's risk to state/federal sanctions and fines- communicate required action to senior management/Board of Governor (BoG), Plan Partner staff. 2. Internal audit program and internal reviews  are indicators of the quality of health care services provided to L.A. Care Medi-Cal members.  This serves to help maintain a quality and solvent provider network and avert provider network disruptions due to poor quality of care and/or insolvent providers. All areas of risk/noncompliance are to be identified, reported and monitored.

Working knowledge of California Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and Knox-Keene requirements, as well as highly developed analytical and critical thinking skills, to serve as a resource to internal business units and external entities.

Preferred:
Advanced skills in Visio, PowerPoint and/or SharePoint preferred.