Job Supervisor of Program Integrity

Program Integrity Unit Manager

Oversees the day-to-day operations of Partnership HealthPlan of California's (PHC) Program Integrity Unit. Responsible for ensuring the timeliness of investigations related to potential or actual HIPAA and fraud, waste, and abuse. Supports training, provides direction to the Regulatory Affairs and Compliance (RAC) staff, and serves as an effective liaison for the organization and its internal and external community.

Responsibilities

• With RAC leadership, supports the management and goal setting for program integrity operations
• Supervises Regulatory Affairs Specialists and ensures staff follow procedures, policies and protocols. Defines scope of work, deliverables and timeframes directly with senior staff
• Researches complex HIPAA and / or fraud cases to ensure accurate and timely response utilizing all applicable State and Federal regulations, available data and documentation, and facts of the case. Facilities case conferences with RAC leadership as needed
• Supports PHC's multi-faceted approach to detect and protect against fraud activity
• Responsible for the completeness and accuracy of the tracking systems and records of all reports and investigations related to potential or actual HIPAA and / or fraud
• Participates and represents PHC in meetings and calls with regulators and associations and summarizes key points and impact to PHC programs
• Provides HIPAA / FWA training and education to PHC operational departments to promote awareness of and adherence with program integrity requirements
• Maintains work plans, dashboards, and other tools intended to provide transparency and accurate reporting of program integrity activities and trends
• Responsible for monitoring industry trends and making recommendations for PHC's program to proactively mitigate HIPAA and / or fraud risks and develops and supports implementation of interventions

Secondary Duties and Responsibilities

Qualifications

Education and Experience

Bachelor's Degree in Liberal Arts, Business Administration, HealthCare Administration, Political Science, or related field with two - three (2-3) years' experience in the health care compliance field, with knowledge of the Knox-Keene and Medi-Cal regulations; or an equivalent combination of education and experience (4-5 years minimum health care experience).

Special Skills, Licenses and Certifications

Certification in Healthcare Compliance (CHC) preferred or obtained within 12 months of hire. Highly proficient in applicable business software applications including PC usage, Microsoft Word, PowerPoint and Excel. Knowledge of Policy development. State and federal legislative processes. Medi-Cal programs. Research and program planning methodology. Project Management. Valid California driver's license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Excellent oral and written communication skills. Excellent organizational skills with ability to prioritize assignments. Perform policy development and implementation in the areas of Medi-Cal, other insurance programs, long-term care, mental health, and other health related programs. Demonstrated analytical skills. Ability to communicate effectively, both verbally and in writing. Perform Project Management activities.

Work Environment And Physical Demands

Ability to use computer keyboard and other business machines. More than 50% of work time is spent at a computer monitor. When required, ability to move, carry, or lift objects of varying sizes, weighing up to 35 pounds.

All HealthPlan employees are expected to :

HIRING RANGE :

$103,059.95 - $133,977.94

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.