Compliance Associate – Care N’ Care (CNC), SWHR

Education

• High School Diploma or equivalent with an additional 4 years of experience in lieu of Bachelor's Degree required,

OR,

• Bachelor’s Degree required.

Experience

• Requires 6 years’ experience in Medicare Advantage or Managed Care industry, with Bachelor’s Degree,

OR,

• Requires 10 years’ experience in Medicare Advantage or Managed Care industry, without Bachelor’s Degree.

Skills & Abilities

• Thorough knowledge of CMS guidelines, process and systems.
• Demonstrated knowledge of regulatory compliance policies and procedures in a managed care environment.
• Solid knowledge of Microsoft Office (Excel, Word, PowerPoint) Ability to handle multiple projects and competing priorities.
• Strong written, verbal, listening and communication skills – having the ability to understand and communicate appropriately to the targeted audience.
• Strong analytical skills – having the ability to identify an issue, conduct an analysis to determine business impact (including gap analyses) and identify solutions.
• Strong project management skills - having the ability to effectively manage multiple priorities simultaneously by maintaining established time frames, adhering to work plans, and communicating changes effectively.
• Ability to work independently and with a team.

Position Responsibilities

The Compliance Associate serves as a role model for ethical and compliant behavior while supporting the company's compliance program. The role provides oversight to the company's operational areas to ensure compliance with laws, rules, regulations, and policies that govern the company's business. The role will be responsible for the coordination and completion of all government, regulatory, and compliance documents related to the company's compliance program.

Position Functions

• Operations:

• Assists the director in the development, implementation, and maintenance of compliance programs, policies and procedures designed to ensure compliance with all applicable federal laws and Medicare Advantage and Prescription Drug Plan (MA-PD) regulations.

• Develop, maintain, and update department policies and procedures as necessary to reflect changes in federal and state laws and regulations.

• Coordinate all CMS readiness activities to ensure the plan is ready for the next benefit year.

• Coordinate, participate, and assist in the development and implementation of the annual risk assessment.

• Participate in the development of the annual compliance work plan.

• Assist in researching, investigating, and analyzing compliance, ethics, fraud waste and abuse, and privacy issues when rendering professional advice to operational areas and senior management.

• Review and interpret HPMS memo and summary guidance, ensuring regulatory requirements are tracked and documented through completion.

• Oversee Medicare Part C & D Reporting requirements, including CMS Data Validation Audit process and Timeliness Monitoring Project.

• Track relevant laws and regulations and direct and guide the operational areas with updating operating manuals and procedural documents when regulations change.

• Marketing:

• Participate in the compliance review and approval process of marketing material and required annual mailings (i.e., ANOC/EOC, Summary of Benefits, and Provider Directory). • Serve as subject matter expert for MA-PD marketing requirements.

• Auditing:

• Assist and support all activities related to delegation oversight to include pre-delegation audits, annual attestation processes, delegation oversight meeting coordination, and issue management.

• Coordinate internal and external audits ensuring timely submissions for audit requests, monitoring compliance with standards and tracking corrective action plans to complete.

 Reporting:

• Prepare compliance reports for internal management, boards and committees, and regulatory agencies as required.

• Coordinate, prepare, and track filing through the Texas Department of Insurance.

 Project Management/Training:

• Assists and supports compliance-related projects and initiatives, participating collaboratively in staff meetings, committees, projects, and teams to resolve issues and meeting compliance program goals.

• Develop and present training on regulatory compliance requirements. In addition, training operational areas on how their function is impacted by CMS requirements.

Why Southwestern Health Resources 

As a Southwestern Health Resources employee, you’ll enjoy, comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.

Additional perks of being an SWHR employee:

• Gain a sense of accomplishment by contributing to a teamwork environment.
• Positively impact patients’ quality of life.
• Receive excellent mentorship, comprehensive training and dedicated clinical and administrative leadership resources.
• Enjoy opportunities for growth.

Explore Southwestern Health Resources Careers for more information and to search all career opportunities.

Our Recruitment team invites you to contact us with any questions at recruitment@texashealth.org