Job Description
The Chief Compliance Officer shall be responsible for leading, overseeing, and managing the Compliance Program and all affiliated programs. The role shall ensure the overall effective operations of our Compliance Program and will coordinate efforts across the enterprise including, but not limited to, health plan operations, functional leadership, Clinical Delivery Entities, and delegated entities.
ESSENTIAL FUNCTIONS :
Participating in enterprise strategy and organizational change planning as a thought leader to ensure compliance program functions meet the organization's goals proactively over time evaluating risk, talent, process and technology ongoing to stay apace with change.
Developing, updating, and implementing Compliance Policies and Procedures ("P&Ps") and supporting protocols required to maintain compliance with all federal and state healthcare program requirements, health plan regulations, and accreditation standards, while ensuring that all Compliance P&Ps are reviewed annually and revised. Reviewing and revising the Code of Conduct, Compliance P&Ps, and processes as necessary to reflect legal, regulatory, and administrative changes, industry best practices, and to address any identified compliance concerns or gaps
Creating and coordinating education training programs to ensure that the Board, officers, employees, First Tier Downstream and Related Entities (FDRs), and other relevant individuals and entities are informed about the Enterprise Compliance Program, our Code of Conduct, the Company's compliance policies and procedures, and all applicable statutory, regulatory, and administrative requirements.
Identifying, prioritizing, and remediating Compliance risks across the health plan, delegated entities, Clinical Delivery Entities, and any other relevant parties, along with developing associated risk mitigation strategies and escalating to the Chief Corporate Affairs Officer, CEO, and Board (as needed).
Developing formal protocols for managing compliance violations, including the development and implementation of corrective action plans, enforcing disciplinary actions, and validation of remediation efforts to ensure regulatory adherence.
Ensuring all Board members, employees, vendors, and entities receive appropriate Compliance education and training, including training on general compliance, fraud, waste, and abuse (FWA), and high-risk compliance areas throughout the enterprise.
Ensuring that required credentialing and federal and state exclusion checks are performed on applicable staff and vendors in alignment with federal and state regulations and industry leading practices.
Serving as Chair of the Executive Compliance Committee, facilitating meetings on a monthly basis or more frequently as necessary, and ensuring appropriate reporting is provided to the Committee, in alignment with regulations and industry leading practices.
Ensuring all Board members, employees, vendors, and entities receive appropriate Compliance education and training, including training on general compliance, fraud, waste, and abuse (FWA), and high-risk compliance areas throughout the enterprise.
Communicating solutions and recommendations across functions demonstrating knowledge of business to successfully integrate compliance mandates into the business to prevent risk.
Conducting an annual, comprehensive Compliance Risk Assessment and developing the annual Compliance Work Plan (aligned with OIG standards) that is presented to the leadership and Board of Directors for review and approval. Conducting regular Compliance auditing and monitoring activities for the enterprise, delegated entities, and Clinical Delivery Entities in accordance with the Compliance Work Plan.
Reporting to the Board of Directors on a quarterly basis, or more frequently as necessary, and providing Compliance Program updates, escalations, and critical decisions needed in alignment with regulations and industry leading practices.
Coordinating company's response to any governmental requests, subpoenas, inquiries, or investigations
Collaborating with our internal legal counsel and outside counsel, as necessary, to address any legal matters or concerns that require compliance expertise
Reviewing, analyzing, and understanding all federal, state, and other relevant regulations that impact company; and assisting with all aspects of operationalization to ensure a compliant enterprise
Other duties as assigned
SUPERVISORY RESPONSIBILITIES :
Supervises / Manages others (i.e. hires, performance reviews, corrective action, etc.)
EDUCATION, CERTIFICATIONS & EXPERIENCE :
Bachelor's Degree (preferred) or equivalent experience
Master's degree in business administration, health care administration, or Juris Doctor preferred
Preferred Certifications or Licenses :
Certification in Healthcare Compliance (CHC), Healthcare Privacy Compliance (CHPC), Health Care Compliance Association (HCCA) membership, and / or course accreditation from HCCA or similar organization preferred.
Experience Preferred :
At least 10 years of experience with healthcare compliance programs, preferably for Medicare Advantage, California Medi-Cal, and Special Needs Programs (e.g., D-SNP, FIDE-SNP, C-SNP, I-SNP).
SKILLS / ABILITIES :
Knowledge of regulatory requirements and industry best practices for compliance programs. This includes not only knowledge of the seven elements of compliance, as required by the OIG and other regulatory agencies, but also hands-on experience in leading, implementing, and managing effective compliance programs.
Knowledge of key health plan operations (e.g., Pharmacy / PBM, claims, risk adjustment) rules, regulations, and guidance.
Knowledge and practical application of the healthcare FWA rules, and regulations, including the Anti-Kickback Law, the Stark Law, the False Claims Act, and applicable California state regulations.
Excellent communication and analytical skills
Ability to seamlessly work in complex environments, including interacting with senior-level executives, clinicians, attorneys, and operations / administrative staff.
COMPETENCIES :
Leadership - Skilled to develop others
Business Insight - In-Depth understanding of the business
Problem Solving - Good problem-solving skills
Strategic Mindset - Anticipates future trends and implications accurately
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