Compliance Officer - Chicago, United States - Cook County Health

Description

POSITION TITLE: Compliance Officer, CountyCare

REPORTS TO: Chief Compliance and Privacy Officer

ORGANIZATION: Cook County Health CountyCare

LOCATION: Chicago, IL

SUMMARY: The Compliance Officer, CountyCare reflects the mission and vision of Cook County Health (CCH), adheres to the organization's Code of Conduct and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines, and all other regulatory and accreditation standards. The Compliance Officer, County Care is responsible for the ongoing development, implementation, maintenance, and evolution of the CCH Health Plan compliance program and all related compliance activities. This includes, but is not limited to, the development and subsequent assessment of comprehensive policies and procedures, protocols, compliance training, and internal investigations.

RESPONSIBILITIES:

• Governs the Health Plan's Fraud, Waste, Abuse (FWA) and Financial Misconduct Program (Program Integrity Program) including delegated Special Investigations Unit (SIU) to ensure that Program Integrity Program and FWA initiatives are actively administered and addressed, as delegated by the Chief Corporate Compliance & Privacy Officer:

o Implements and coordinates communication protocols and methods that encourage CCH workforce/employees, independent contractors, and delegated vendors to report issues related to noncompliance and FWA without fear of retaliation

o Coordinates and oversee fraud investigations and referrals conducted by delegated SIU's, where applicable o Collaborates with other Medicaid health plans, HFS, the HFS Office of Inspector General, Medicaid Fraud Control Units (MCFUs), local law enforcement, commercial payers, and other organizations, where appropriate, when a potential FWA issue is discovered that involves multiple parties.

o Ensures that FWA is reported in accordance with federal, state and local requirements, as well as the guidelines in the Medicaid Managed Care regulations at 42 CFR § and the CCH Managed Care Community Network (MCCN) Agreement with Illinois Department of Healthcare Family Services (HFS)

• Serves in a leadership capacity to develop the Health Plan compliance program in conjunction with the Chief Corporate Compliance & Privacy Officer

• Chairs and facilitates the executive Regulatory Compliance Committee meeting on a quarterly basis

• Develops, implements, maintains, and assesses/updates compliance policies and procedures to ensure adherence with relevant regulatory and requirements

• Modifies health plan policies, procedures, and projects to reflect changes in laws and regulations

• Establishes a structured process for regulatory review, monitoring, and dissemination of information

• Reviews health plan agreements, contracts, addenda, and other relevant documents, as needed

• Oversees, directs, delivers, tracks, or ensures delivery of compliance training and communications, both general in nature and specialty, for employees, workforce, network providers, vendors, and consultants

• Aligns with Health Plans' operations regarding sanction/exclusion checks to verify that CountyCare network providers, employees, workforce, vendors, and consultants (where necessary) are screened against applicable Federal and State sanction and exclusion lists

• Coordinates with Health Plan provider network contracting to ensure new providers undergo a FWA review

• Establishes and administers a process for receiving, documenting, tracking, investigating, and taking action on all compliance concerns: o Investigates reports of alleged non-compliance to determine the validity, nature and scope of the report in conjunction with the designated team members, as identified by the Chief Corporate Compliance & Privacy Officer

o Performs interviews with key personnel to validate compliance with established policies and procedures and applicable regulations in conjunction with reports of alleged non-compliance, as deemed necessary

o Develop reports upon completion of each compliance review, which details recommendations designed to correct any potential weaknesses or areas of non-compliance discovered during the review

o Performs follow-up reviews to ensure action plans have been adequately implemented

o Collaborates with operational areas to remediate concerns through action plans to correct potential weaknesses and assure ongoing compliance

• Develops and coordinates compliance projects with CCH entities, which may be ad-hoc or delineated in the Compliance Program Annual Work Plan and perform prospective reviews in conjunction other personnel as deemed necessary, and as requested by the Chief Corporate Compliance & Privacy Officer

• Develops vendor-specific annual audit protocols, performs audits, review results, and determines if regulatory and requirements requirement are met

• Produces and delivers Compliance Program reports for CCH and Health Plan Leadership, the Board of Directors, and/or the Audit and Compliance Committee of the Board of Directors, as directed by the Chief Corporate Compliance & Privacy Officer

• Collaborates with Health Plan Leadership to facilitate operational ownership of compliance

• Monitors operational management of the Health Plan complaint, grievance, appeals and fair hearing processes for program compliance including review of trends and patterns through reports and data analysis

• Maintains highest levels of confidentiality regarding all departmental operations in both verbal and written and with the use of technology

• Works with minimal supervision and use time effectively

• Maintains a high degree of follow-through despite frequent interruptions

• Performs other duties as assigned

QUALIFICATIONS:

• Master's degree in healthcare, business, education, or related field from an accredited college or university or a Juris Doctor (J.D.)

• Experience in a hospital or a large multi-specialty clinic setting with experience in the areas of

compliance, audit, risk, quality and/or legal

• Five (5) years recent managerial/supervisory experience in a health plan

• Three (3) years of conducting complex healthcare analysis and/or investigations

• Project Management experience

• Leadership competencies to include planning and organizing, problem solving, informing,

consulting, supporting, and networking

• Knowledge of coding, billing, medical records, review/analysis, and documentation

• Professional Registration/Certification or compliance/fraud related healthcare credentials,

current & active, including but not limited to RHIA, CPA, CFE, AHFIm CFE, HIA, HCAFA, MHP or

CHC

• Health plan experience

• Knowledge and experience with extensive report development and policy and procedure

development

• Knowledge of Health Care Regulatory standards

• Excellent verbal and written communication skills necessary to communicate with all levels of

staff and a patient population composed of diverse cultures and age groups

• Familiarity with public speaking and business presentations

• Strong working proficiency with Microsoft Office (Access, Excel, PowerPoint, and Word)

• Demonstrate analytical and organizational, problem-solving, critical thinking, and conflict

management/resolution skills

• Demonstrate attention to detail, accuracy, and precision

• Behavioral commitment to quality work and customer service philosophy

• Ability to work in a fast-paced environment, which requires handling multiple tasks at once

• Ability to maintain a professional demeanor and composure when challenged

• Ability to function autonomously and as a team member in a multidisciplinary team

• Ability to travel to and from any CCH locations

CONTACT:

Qualified candidates expressing interest in the opportunity, please submit a resume/CV and cover letter with Compliance Officer in the subject line to or

This position is exempt from Career Service under the CCH Personnel Rules