VP Coverage Compliance

VP Coverage Compliance

VP Coverage Compliance is responsible for planning, developing, and enforcing compliance programs for Baylor Scott and White Health (BSWH) and specifically for the Baylor Scott and White Health Plan (BWSHP) and Baylor Scott and White Quality Alliance (QA), collectively known as the "Coverage" system. This includes Health Plan and QA compliance and in partnership with the system to provide compliance hotline services, conflicts of interest, education, communications, and other compliance activities. The VP Coverage Compliance leads the development of compliance programs to prevent and detect non-conformance to laws, regulations, standards, and BSWH policies and ensures the implementation of a compliance program for assigned area of the organization. The leader develops and implements strategies, policies, procedures, and practices that establish BSWH standards for compliance and ensures compliance to all applicable laws, regulations, and accreditation standards, such as the Joint Commission, Centers for Medicare and Medicaid (CMS), National Committee for Quality Assurance (NCQA), Health Insurance Portability and Accountability Act (HIPAA), and Occupational Safety and Health Administration (OSHA). The leader anticipates, responds and reacts to changes and developments in laws or the regulatory environment that might affect BSWH compliance and implements necessary changes. The leader investigates, audits, and remediates alleged violations or incidents of nonconformance and verifies that compliance deficiencies have been corrected. The leader provides key support and regular reporting to the Audit and Compliance Committee of the BSWHP and QA Boards. The leader may develop and implement employee compliance training curriculum. The leader collaborates closely with leaders with the Coverage business unit as well as executive leadership, operations, legal, risk management, finance, and Information Security to identify and resolve compliance issues in accordance with overall BSWH business objectives.

Essential Functions

• Sets the strategic plan and priorities for Coverage Compliance system and oversees the Coverage Compliance system for BSWH.
• Ensures the compliance program meets all applicable regulatory requirements of government regulatory entities, including the Health and Human Services Commission (HHSC), Office of Inspector General (OIG), the Centers for Medicare and Medicaid Services (CMS), and the Texas Department of Insurance (TDI).
• Manages and oversees the Health Plan NCQA accreditation process and the NCQA accreditation process for Coverage care management.
• Leads ethics and integrity initiatives, including the review, update, and dissemination of the code of conduct and conflict of interest programs.
• Oversees the annual review, revision, and communication of Coverage compliance policies and procedures of all legal, regulatory, and accreditation requirements.
• Leads the development, delivery, and tracking of appropriate compliance education and training programs for employees, network providers, and leadership.
• Organizes and leads the Coverage Compliance Committees, including development of appropriate agendas, reporting, and related information and is an active member of the Coverage leadership team in reporting updates and critical matters to the various boards.
• Oversees the development and implementation of anti-fraud program, including the coordination of internal investigations, anti-retaliation controls, reporting of violations as appropriate.
• Conducts annual risk assessment across the Coverage team, prioritizes the identified risks for inclusion in the annual compliance auditing and monitoring work plan.
• Leads the development and implementation of metrics and dashboards related to the auditing and monitoring work plan and works closely and compatibly with business leaders in remediating issues, including corrective action plans.
• Is an active and visible member of the Coverage system leadership team.

Key Success Factors

Minimum Requirements