http://kpcareers.org/careers/compliance,-privacy,-and-regulatory-jobs en Oakland, CA

The Compliance Consultant IV is responsible for overseeing Kaiser Permanente's compliance with federal and state insurance laws, regulations and sub-regulatory guidance through the planning and implementation of compliance systems and initiatives. On an on-going basis, Will be responsible for leading compliance's national engagement for several health plan and health care reform initiatives through research and interpretation of regulations and laws to establish compliance standards/requirements, and working with compliance partners and health plan business leads to integrate compliance standards into operations.
Researches, plans, implements, and monitors a broad portfolio of compliance systems and initiatives to enable organizational compliance with all applicable Federal, state, and local regulations/laws, as well as overseeing the protection of organizational assets. On an on-going basis, researches and interprets regulations and laws to establish compliance standards, and may develop and/or deliver training and communications/change management relative to new standards. Assesses organizational systems (both physical and process or data related) to determine gaps in compliance and determine opportunities for remediation. Advises the organization on all compliance matters. May investigate violations of compliance policy, laws, regulations, etc. or conduct on-going monitoring and reporting to ensure remediation. May be responsible for project management relative to new compliance initiatives, products, or annual processes.

Essential Functions:
- National Compliance Lead for health plan and health care reform initiatives. Will be responsible for coordinating with national and regional compliance partners to determine compliance's engagement strategy for the initiatives, developing and integrating compliance standards/requirements, and leading and/or supporting assessments and audits.
- Manages, creates, and maintains client relationships with management at all levels of the organization
- In adherence with the KP Compliance Framework, fosters comprehensive compliance management through a series of activities to comply with all applicable regulations and statutes. Activities include
- Planning: Leading the identification of compliance accountabilities; identification of internal and external resources; development of Compliance, Work, and Audit plans; establishing and/or leading compliance-related committees/work groups; and managing external agency relations,
- Implementing: Leading the identification of compliance requirements and directing related analyses; creation and revision of compliance standards, policies, and procedures; overseeing development and/or delivery of compliance and ethics training; leading the monitoring of compliance adherence; and directing reporting on compliance efforts and programs, and
- Validating: Reviewing compliance programs and content, including leading the design and implementation of risk assessments and/or audits, and overseeing the investigation of instances of reported non-compliance
- Researches and stays abreast of regulations and statutes. Determines impacts of implementation of new regulations and statutes and required notifications, changes, and training. Communicates required changes, develops tools to assess risks, and leverages existing workgroups/etc. to facilitate required changes. May engage external regulatory and legislative bodies on developing regulations and laws, providing input and representing Kaiser Permanente's interests
- Works on significant and unique assignments of diverse and complex scope
- Addresses opportunities for process improvements and influencing change
- Requires more complex planning and direction setting with diverse and multiple stakeholders
- Responsibilities impact the achievement of integrated functional and/or KP objectives. In addition, responsibilities impact relationships with external regulatory agencies
- Influences the development of the functional objectives
- Erroneous decisions or recommendations would normally result in failure to achieve functional and/or KP objectives and negatively affect expenditures and resources
- Involves a high degree of interpretation and analysis of obscure or inconclusive data
- Requires a high level of judgment and risk taking to make appropriate decisions for diverse, sophisticated, and undefined issues
- Assume other duties as directed
- Knowledge of health insurance laws, regulations, practices and standards.
- Experience with implementation/administration of insurance products.
- Knowledge of health care compliance policies, practices, and systems.
- Ability to develop advanced compliance principles, theories, and concepts.
- Strong critical thinking, problem solving, and oral and written communication skills.
- Strong, clear written and verbal communication skills to varying levels of the organization.
- Strong project management skills; ability to lead and manage operational and tactical aspects of multiple projects simultaneously.
- Demonstrate ability to timely plan, execute, and complete projects within strict deadlines.
Additional Skills/Knowledge
- Experience with interpreting laws and regulations and ability to identify and partner with business to communicate impact and compliance expectations - Familiarity with health insurance laws and regulations
- Experience with integrating compliance within system/application implementations preferable
- Familiarity with health plan operations and experience with projects in at least one health plan functional area preferable
- Ability to lead and manage operational and tactical aspects of multiple projects at the same time
- Plans, executes, and finalizes projects according to strict deadlines
- Ability to collaborate with multiple functions and departments, across various levels of the organization
- Strong critical thinking, problem solving, and oral and written communication skills

Qualifications:

Basic Qualifications:
- Required: Eight (8) to twelve (12) years of heath care compliance, health care operations (quality, risk, etc.), audit, finance, project management, regulatory or public policy development, investigations, information security, or insurance/health plan governance experience.
- Four (4) year or clinical degree or equivalent experience.
- Advanced knowledge of health care compliance policies, practices, and systems.
- Contributes to the development of compliance principles, theories, and concepts.
- Broad knowledge of health care industry practices and standards.
- Ability to draft and revise documents including policies, standards, analyses, and reports.
- Project management skills
- Advanced knowledge of health care and related compliance issues.]]> Mon, 14 May 2012 16:00:00 GMT 2429278-Oakland-Compliance,-Privacy,-and-Regulatory Regulatory Services Director - Survey and Provider Dispute Response
Kaiser Permanente
Oakland or Pasadena, CA


The Regulatory Services Director is for serving as the liaison with California State Regulator, Department of Managed Health Care (DMHC) for onsite regulatory surveys.

Specific duties include:
- DMHC Surveys
Help KP prepare for Routine and Non-Routine DMHC Surveys
- Pre-survey and on-site document submission for Routine and Non-Routine surveys
- Coordination of Opening and Exit Conferences for surveys
- Coordinate, prepare, and file responses for the Preliminary and Final Survey Reports
- Serve as direct-point-of contact with regulator for all survey issues
- Partner with HPRS units and operational stakeholders statewide to prepare for surveys and develop responses to survey reports and corrective action plans - including interview preparation with stakeholders
- DMHC Corrective Action Plan Management includes:
Coordination of Corrective Action Plan with responsible operational area for submission to DMHC Oversight of implementation of Corrective Action Plans Ongoing monitoring of Corrective Action Plans
DMHC Provider Disputes
- Respond to payment disputes received by DMHC from non-KP providers
DHCS Fair Hearings
- Represent KP at State Fair Hearings initiated by Medi-Cal members
Personnel Management: Manages the efforts of direct reporting, as well as matrix reporting, positions. Responsible for selecting, developing, and deploying personnel in the most effective manner to meet objectives. Responsible for performance management, compensation decisions, and providing on-going, regular developmental feedback. Influences performance management, compensation decisions, and ongoing feedback for individual contributors reporting to direct report managers, possibly through more than one layer of subordinate management.

Communications, Stakeholder Management, and Negotiation of Agreement: Facilitates communications, manages relationships with stakeholders, and garners support and agreement from involved parties for compliance initiatives and programs for functional areas across the enterprise.

Issue Management, Response, and Mitigation: Responsible for issue management, response, and mitigation for functional areas across the enterprise. Proactively identifies risks and issues related to projects and production operations. Anticipates and addresses issues through regular communication with reporting positions and other internal and external parties at all levels, mitigating risk or, in the most severe cases, escalating issues for resolution by more senior levels as necessary.

Change Management: Responsible for leading change management efforts for functional areas across the enterprise. Identifies and acts upon opportunities to leverage direct reporting team in change management activities; ensures direct reporting team is engaged in change management as appropriate.

Project Management: Responsible for management of project plans for objectives or
projects for functional areas across the enterprise as well as ensuring project timelines and objectives are met for projects managed by reporting positions.

Strategic development: Participates in the identification and development of objectives, goals, and strategy relative to functional areas across the enterprise.

Qualifications:

Minimum Requirements

5-8 years of management experience and 10-12 years progressively-responsible health care administration or regulatory experience.
Expert knowledge of regulatory policies, practices and systems.
Expert knowledge of regulatory-related practices and standards.
Project management skills
Expert knowledge of state regulatory environment
4-year or clinical degree or equivalent experience
Master's degree or JD degree preferred .]]> Sun, 13 May 2012 16:00:00 GMT 2424149-Oakland-Compliance,-Privacy,-and-Regulatory Kaiser Permanente
Oakland or Pasadena, CA or any KP Region

This Position is responsible for partnering with regional Pharmacy personnel, Pharmacy Fraud Control, Pharmacy Compliance, , Enterprise Governance, Risk and Compliance (eGRC) initiatives and National Compliance's various departments (management and analysts) to conduct and document complex Pharmacy-related analyses identified from analytic tools within iACT and pharmacy. Adhere to eGRC reporting and monitoring and review, document and present to NSIU and / or Regional Subject Matter Experts (SME). Identifying best practices and process improvement surfaced by internal analytics.

Researches, plans, implements, and monitors a broad portfolio of compliance systems and initiatives to enable organizational compliance with all applicable Federal, state, and local regulations/laws, as well as overseeing the protection of organizational assets. On an on-going basis, researches and interprets regulations and laws to establish compliance standards, and may develop and/or deliver training and communications/change management relative to new standards. Assesses organizational systems (both physical and process or data related) to determine gaps in compliance and determine opportunities for remediation. Advises the organization on all compliance matters. May investigate violations of compliance policy, laws, regulations, etc. or conduct on-going monitoring and reporting to ensure remediation. May be responsible for project management relative to new compliance initiatives, products, or annual processes.

Major Responsibilities:

Analysis includes Part D and other pharmacy related usage, payment and statistical review of analytic findings.
Categorization and presentation of findings with recommendation of action(s).
Recommendations could include internal prepayment review or process improvement recommendations
Application of eGRC documentation rules and use of eGRC system(s)
Compliance analysis and impact/ risk assessment.
Assist with designing analyses and project management of technical and business processes relating to Medicare rules and regulations Fraud, Waste and Abuse requirements Improvement of existing algorithms.
Prepare and present recommendations with supporting documentation (gleaned from internal and external sources) to Investigator(s).
Provide training to regional Pharmacy departments as needed
Understand and document business systems / processes using narrative and/or flowcharting techniques.
Using quantitative and qualitative methods, capture and present external and internal experts findings
Perform in depth root-cause analysis related to findings and design solution and implementation process in coordination with operational business partner
Prepare and deliver analyses and recommendations to management.
Understanding of technology involved. Create and maintain detailed project, analyses and communication plans. Ability to interact with Information Technology personnel
Understanding of oversight and risks in the Pharmacy area
Creation of education and training program. Provide education and training as needed.
Requires excellent judgment to identify best solutions from existing alternatives.
Interacts regularly with various Regional Pharmacy personnel, management and staff, National Compliance Office, Regional Pharmacy management, Fraud Control Manager and National Special Investigations Unit.


Qualifications:

Basic Qualifications:
- Required: Five (5) to eight (8) years of heath care compliance, health care operations (quality, risk, etc.), audit, finance, project management, regulatory or public policy development, investigations, information security, or insurance/health plan governance experience
- Four (4) year or clinical degree or equivalent experience
- Expert analysis, which includes prescriptions, payment and statistical review of analytic findings.
- Experience and understanding of oversight and risks in the Pharmacy area
- Thorough knowledge of health care compliance policies, practices and systems
- Complete understanding of compliance principles, theories, and concepts
- Full knowledge of health care industry practices and standards
- Ability to draft and revise documents including policies, standards, analyses, and reports
- Project management skills

Preferred Qualification
- Thorough knowledge of health care and related compliance issues]]> Tue, 08 May 2012 16:00:00 GMT 2414967-Oakland-Compliance,-Privacy,-and-Regulatory Kaiser Permanente
Oakland or Pasadena, Ca

Health Plan Regulatory Services (HPRS) is responsible for leading CA state regulatory initiative across all functions statewide, as well as managing relationships and maintaining communication with stakeholders at all levels, both internally and externally.

Essential Functions:
- Researches, plans, implements, and monitors a broad portfolio of regulatory systems and initiatives to enable organizational compliance with all applicable Federal, state, and local regulations/laws.
- Advises the organization on all regulatory matters related to the Department of Managed Health Care (DMHC) and other state regulators.
- On an on-going basis, researches and interprets regulations and laws to establish standards, and may develop and/or deliver training and communications/change management relative to new standards.
- Assesses organizational systems (both physical and process or data related) to determine gaps in compliance and determine opportunities for remediation.
- Advises the organization on all compliance matters.
- May investigate violations of compliance policy, laws, regulations, etc. or conduct on-going monitoring and reporting to ensure remediation.
- May be responsible for project management relative to new compliance initiatives, products, or annual processes.

HPRS is responsible for:

- Assessment of organizational systems and processes to ensure appropriate Health Plan oversight and survey readiness and determine gaps for remediation prior to regulatory surveys.
- All regulatory filings related to Health Plan's Knox-Keene license (ex. contracts, benefits, delivery systems, new products)
- Benefits interpretation to ensure statewide consistency in providing benefits to members and compliance with benefits provisions in contracts
- Processing regulatory complaints in a timely manner and trending, reporting, and analyzing data related to these complaints
- May be responsible for project management relative to new regulations, legislation, surveys, new products, or other issues involving state regulators
- Developing and directing proactive regulatory strategies to support membership growth

Job Specific Function Summary

Responsible for supporting all aspects of HPRS engagement in projects and issues related to the implantation of and compliance with the Affordable Care Act (ACA).
- Understands all aspects of ACA and state laws relating to Health Care Reform (HCR) and how they impact the organization.
- Researches state and federal health care reform requirements and regulations and partners with other units in HPRS to identify impact.
- Communicates information relating to new/developing HCR requirements to other HPRS units.
- Works with Manager and Executive Director on the Health Plan's response to DMHC on requests for information.
- Responds to internal inquiries and requests for information on KP's regulatory response to ACA requirements and regulator interpretation of ACA requirements.
- Represents HPRS at various internal meetings on topics relating to Health Care Reform.
- Supports manager and other HPRS stakeholders in preparing DMHC filings related to ACA/HCR requirements.
- Partners with other internal compliance entities on topics and projects relating to ACA/HCR.
- Customer and Industry Knowledge: Advanced knowledge of health care and related regulatory issues.

Qualifications:

Basic Qualifications:
- Required: Eight (8) to twelve (12) years of health care experience - health care operations (quality, risk, etc.), audit, finance, project management, regulatory or public policy development, investigations, information security, or insurance/health plan governance experience.
- Preferred: Same.
- Four (4) year or clinical degree or equivalent experience.
- Advanced knowledge of health care regulatory policies, practices and systems.
- Contributes to the development of regulatory concepts.
- Broad knowledge of health care industry practices and standards.
- Ability to draft and revise documents including policies, standards, analyses, and reports.
- Project management skills.
- Advanced knowledge of health care and related regulatory issues.]]> Mon, 07 May 2012 16:00:00 GMT 2415035-Oakland-Compliance,-Privacy,-and-Regulatory
Essential Functions:
- Coordinate, lead, and monitor the core functions of the Regional Audit Program for coding and revenue cycle compliance to include ensuring that the day-to-day work functions are appropriately allocated and addressed. Participate in the implementation of Incident-To billing services and facilitate the coding and revenue compliance functions such as documentation and coding guideline verification, training program development and go-live support fro both clinical and non-clinical medical office staff.
- Lead new initiatives related to internalization of services to ensure that all compliance requirements are met and that the appropriate technical support is provided for each implementation.
- Organize and facilitate the distribution of Regional Audit Program audits, collate results, analyze findings, assist in the preparation of written audit reports complete with findings and recommendations. Communicate reports to the Coding and Revenue Cycle Compliance Manager and others as appropriate/requested.
- Address any identified trends, patterns, or system issues that may contribute to claims, coding, provider contracting, and revenue cycle deficiencies. Update and present recommendations to Coding and Revenue Cycle Compliance Manager and other affected functional areas as appropriated/requested.
- Developing, implementing and completing corrective action plans for all noted deficiencies
- Ensure that all reviews and audits are based on the most current federal regulatory requirements and coding and documentation guidelines
- Regularly collaborate with peers within regional HIMS, Claims, Appeals, Member Services, National Medicare Finance (NMF), Medicare Operations, Medicare Compliance, Clinical Affairs, Professional Development and Provider Contracting departments to assure integration of the coding and revenue compliance program into operations as well as communication of findings, report on trends and patterns, and avoid redundancy of the work effort
- Conduct education and training of staff members and other functional areas related to the core functions of the Coding and Revenue Cycle program or as identified by the Coding and Revenue Cycle Compliance Manager
- Serve as a subject matter expert (SME) for coding, documentation and revenue cycle concerns within the region
- Lead the coordination of both internal and external audit work as necessary



Qualifications:

Basic Qualifications:
- Bachelor's Degree or a combination of equivalent related education and work experience
- Five or more years experience in the coding field including or in addition to experience as a coding auditor. Additional experience in reimbursement and/or compliance functions will be valuable
- Three to five (3-5) years of reimbursement and/or revenue cycle experience
- A minimum of five years coding and/or auditing experience at all coding levels including facility inpatient, outpatient, and professional services as well as three years of project management or related experience
- Experience must include work opportunities that have allowed for the evolution of a strong coding and/or auditing background relating to core functional area of the Coding and Revenue Cycle Program outlined above.
- Demonstrated ability to provide effective statistical analysis and analytical problem solving
- Strong working knowledge of the critical elements of the auditing process
- Very strong computer skills including use of Microsoft Office Suite of Products and other software programs to manage audit data
- Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization
- Well-developed oral and written communication skills for representation of clear, concise results of completed audit/monitor
- Knowledge of health insurance laws and regulations required
- Requires in-depth knowledge of ICD-9-CM and CPT-4 Coding systems and knowledge of HCPCS Level II coding system and APC/ASC coding systems
- Working knowledge of medical terminology, disease processes, and pharmacology
- Ability to adapt to different work environments and to communicate effectively with verbally and in writing with a wide range of health care professionals including clinicians, managers, and coders
- Some travel required
- Credential as a Certified Coding Specialist (CCS), Certified Coding Specialist-Physician and/or Certified Professional Coder (CPC) is required
- Credential as a Certified Healthcare Compliance (CHC) professional (or within two years of hire)

Preferred Qualifications:
- Bachelor's Degree in Health Information Management Systems or a related field
- Certification through the American Health Information Management Association as a Certified Coding Specialist; CCS or RHIT (Registered Health Information Technician) or RHIA (Registered Health Information Administrator)
]]> Mon, 16 Apr 2012 16:00:00 GMT 2355422-Atlanta-Compliance,-Privacy,-and-Regulatory Project Manager, National Compliance Office
Oakland or Pasadena, CA

Kaiser Permanente is looking for aProject Managerin Oakland or Pasadena. This person will provide support for the National Compliance Office's projects, assessments, and audits.


Essential Functions:
Communicates required changes, develops tools to assess risks, and leverages existing workgroups/etc. to facilitate required changes.
Responsibilities impact the achievement of key department, functional, or stakeholder objectives.
Contributes to the achievement of department objectives.
Erroneous decisions or failure to achieve department objectives would normally affect expenditures and resources.
Involves interpreting and analyzing established concepts and trends.
Exercises judgment to make decisions for less defined issues and selects methods and techniques for obtaining solutions.
Requires moderately complex decision-making.
Develops solutions to complex problems. May refer to established precedents and policies.
Requires significant analysis to develop solutions for complex problems.
Provides professional/technical guidance to team members and stakeholders.
Communicates and influences acceptance and adherence to policies, practices, procedures of both an interpretive and non-interpretive nature.
Support the team in researching and staying abreast of regulations and statutes.
5-10% travel.


Qualifications:

Basic Qualifications:
- 5+ years of heath care compliance, health care operations, audit, finance, project management, regulatory or public policy development, investigations, information security, or insurance/health plan governance experience
- Ability to draft and revise documents including policies, standards, analyses, and reports
- 4-year degree or 4 additional years of equivalent work experience
- Excellent written/verbal communication skills
- Ability to draft and revise documents including policies, standards, analyses, and reports
- Project management skills

Preferred Qualifications
- Knowledge of healthcare and/or compliance
- Proficiency with MS Office (Word, Excel, PowerPoint) and Lotus Notes
]]> Tue, 10 Apr 2012 16:00:00 GMT 2334629-Oakland-Compliance,-Privacy,-and-Regulatory Senior Audit Manager, Internal Audit Services
Oakland, Pasadena, Denver, Atlanta, Rockville, Portland, Cleveland, or Honolulu


Kaiser Permanente is looking for a Senior Audit Manager.


Essential Functions:

- Manages the planning, scheduling and supervision of assigned audit projects and staff in accordance with the audit plan, project budgets, and milestones.
- Conducts audits, reviews and advisory services that are risk based and include consideration of program-wide integrated audit plans, and KP strategy.
- Reviews and approves risk assessments, develops audit plan programs, reviews work papers, and approves/prepares reports. Adheres to professional and IAS standards.
- Hires, develops, and manages an effective and diverse workforce. Supports coordination of the assigned practice area team.
- Contributes to practice area developmentbased on risk assessment activities, client interactions, and practice area knowledge. Participates in the on-going risk assessment process. Serves as an advisory resource to IAS staff for practice area subject matter. Develops and builds client relationships with the practice area. Coordinates with other audit and compliance functions to maximize efficiency and coverage of key risk areas.
- Works with other members of the management team to identify and contribute to continuous improvement efforts.
- Interacts regularly with various Regional management, Internal Audit management and staff,and external auditorsand consultants.
- Plans, schedules, and manages multiple various and diverse audit projects independently with minimal after-the-fact direction.
- Up to 35% travel.


Qualifications:

Basic Qualifications:
- 7+ years auditing or comparable experience
- Increasing levels of internal audit and project management experience
- Extensive knowledge, skills and experience in the principles and practices of internal auditing in accounting, financial and operational environments, including auditing business functions and information technology systems
- Extensive general accounting, financial, and business skills, knowledge and experience
- One of following certifications is required:
Certified Internal Auditor (CIA)
Certified Public Accountant (CPA)
Certified Information System Auditor (CISA)


Preferred Qualifications:
- Work experience within Internal Audit Services
- 2+ years lead/supervisory experience
]]> Mon, 02 Apr 2012 16:00:00 GMT 2115177-Los-Angeles-Compliance,-Privacy,-and-Regulatory Compliance Consultant V- National Compliance, Ethics & Integrity Office (NCO)
Health Plan & Health Care Reform
Kaiser Permanente
Oakland or Pasadena, CA

The Compliance Consultant V is responsible for overseeing Kaiser Permanente's compliance with federal and state insurance laws, regulations and sub-regulatory guidance through the planning and implementation of compliance systems and initiatives. On an on-going basis, researches and interprets regulations and laws to establish compliance standards, and works with the business and compliance partners to integrate compliance standards into operations. Supports national and regional functions with the implementation of NAIC model rules. Supports regions with establishing standards and best practices for market conduct examinations; and monitoring and reporting on remediation of findings and corrective action plans.

Assesses organizational systems (both physical and process or data related) to determine gaps in compliance and determine opportunities for remediation. Advises the organization on all compliance matters. May investigate violations of compliance policy, laws, regulations, etc. or conduct on-going monitoring and reporting to ensure remediation. May also be responsible for project management relative to new compliance initiatives, products, or annual processe

Essential Functions:
- Manages, creates, and maintains client relationships with management at all levels of the organization
- In adherence with the KP Compliance Framework, fosters comprehensive compliance management through a series of activities to comply with all applicable regulations and statutes. Activities include
- Planning: Leading the identification of compliance accountabilities; identification of internal and external resources; development of Compliance, Work, and Audit plans; establishing and/or leading compliance-related committees/work groups; and managing external agency relations,
- Implementing: Leading the identification of compliance requirements and directing related analyses; creation and revision of compliance standards, policies, and procedures; overseeing development and/or delivery of compliance and ethics training; leading the monitoring of compliance adherence; and directing reporting on compliance efforts and programs, and
- Validating: Reviewing compliance programs and content, including leading the design and implementation of risk assessments and/or audits, and overseeing the investigation of instances of reported non-compliance
- Researches and stays abreast of regulations and statutes. Determines impacts of implementation of new regulations and statutes and required notifications, changes, and training. Communicates required changes, develops tools to assess risks, and leverages existing workgroups/etc. to facilitate required changes. May engage external regulatory and legislative bodies on developing regulations and laws, providing input and representing Kaiser Permanente's interests
- Works on significant and unique assignments of diverse and complex scope
- Addresses opportunities for process improvements and influencing change
- Requires more complex planning and direction setting with diverse and multiple stakeholders
- Responsibilities impact the achievement of integrated functional and/or KP objectives. In addition, responsibilities impact relationships with external regulatory agencies
- Influences the development of the functional objectives
- Erroneous decisions or recommendations would normally result in failure to achieve functional and/or KP objectives and negatively affect expenditures and resources
- Involves a high degree of interpretation and analysis of obscure or inconclusive data
- Requires a high level of judgment and risk taking to make appropriate decisions for diverse, sophisticated, and undefined issues
- Assume other duties as directed
- Experience working with health insurance regulators and health plan oversight bodies (e.g., Department of Insurance, Department of Managed Health Care), particularly Market Conduct Examinations.
- Knowledge of health insurance laws, regulations, practices and standards.
- Experience with implementation/administration of insurance products.
- Experience with and knowledge of National Association of Insurance Commissioners (NAIC) model rules and other standards.
- Knowledge of health care compliance policies, practices, and systems.
- Ability to develop advanced compliance principles, theories, and concepts.
- Strong critical thinking, problem solving, and oral and written communication skills.
- Strong, clear written and verbal communication skills to varying levels of the organization.
- Strong project management skills; ability to lead and manage operational and tactical aspects of multiple projects simultaneously.
- Demonstrate ability to timely plan, execute, and complete projects within strict deadlines.




Qualifications:

Basic Qualifications
Minimum 10 - 12 years of health care compliance, health care operations (quality, risk, etc.), audit, finance, project management, regulatory or public policy development, investigations, information security, or health insurance/health plan governance experience.
4 year Bachelor's degree or Master's degree preferred.
Experience working with health insurance regulators and health plan oversight bodies (e.g., Department of Insurance, Department of Managed Health Care), particularly Market Conduct Examinations/Field Market Examinations to ensure adherence to State laws regarding discrimination and/or fair claims practices.
Regulatory experience ensuring compliance with State insurance codes (e.g., California Insurance Code) and other insurance laws as related to insurance rating, underwriting and claims issues. Knowledge of health insurance laws, regulations, practices and standards.
Experience with implementation/administration of insurance products.
Experience with and knowledge of National Association of Insurance Commissioners (NAIC) model rules and other standards.
Knowledge of health care compliance policies, practices, and systems.
Ability to develop advanced compliance principles, theories, and concepts.
Ability to draft and revise documents including policies, standards, analyses, and reports.
Strong critical thinking, problem solving, and oral and written communication skills.
Strong, clear written and verbal communication skills to varying levels of the organization.
Strong project management skills; ability to lead and manage operational and tactical aspects of multiple projects simultaneously.
Demonstrate ability to timely plan, execute, and complete projects within strict deadlines.

Preferred Qualifications
Experience with interpreting laws and regulations and ability to identify and partner with business to communicate impact and compliance expectations.
Consistent demonstration of appropriate business judgment in timing and communication.
Familiarity with health plan operations and experience with projects in at least one health plan functional area preferable
Ability to collaborate with multiple functions and departments, across various levels of the organization
Experience with applying technical and analytical skills to identify violations of insurance laws.
Experience with developing and issuing corrective action plans as a component of risk mitigation.
]]> Thu, 22 Mar 2012 16:00:00 GMT 2288436-Oakland-Compliance,-Privacy,-and-Regulatory Under general direction of the Exec Director, directs & manages Risk Mgmt, Patient Safety, Accreditation & Licensing, & Medical Staff Services. Develops, plans, designs, delivers, evaluates, & improves an integrated clinical risk mgmt & patient safety system integrated across all in & out-patient departments in a medical center. Includes programs to achieve the proactive prevention, identification, elimination or reduction of the number & severity of clinical risks/losses. Meets regularly w/ medical center leadership including Exec Director, Medical Director, Medical Group Admin, Quality Director, Physician champions for quality & risk, etc to align medical center programs & initiatives w/ organizational business, clinical, & financial goals/objectives. Accountable for tracking the number & severity of risks/losses & serious incidents & for implementing risk reduction & loss prevention activities to meet performance targets related to patient safety/continuous quality improvement.

Essential Functions:
- The Director, Risk MGMT & PT Safety develops & manages an integrated strategy across all Med center clinical depts & associated out-patient depts that includes the development, utilization & assessment of uniform systems, processes/techniques, as well as policies /procedures & interventions to assess & identify risks, minimize/reduce or prevent losses/risks, meet defined performance mgmt/improvement targets/benchmarks, meet regulatory/accreditation standards related to Risk Mgmt, improve the quality of patient care, manage claims quickly, economically & effectively so as to minimize financial consequences /costsAlso directs Med Staff Services & develops systems & processes to ensure regulatory compliance in that area
- Works collaboratively w/ other Med center disciplines/depts (eg, Quality, Accreditation, Regulation & Licensing, Compliance, Member Services, Finance), & Regional depts (eg, Risk Mgmt, Claims/Legal, Environmental Health & Safety) to design & implement risk mgmt & loss prevention strategies & programs, as well as performance improvement programs
- Directs & manages the identification/measurement & assessment of risk through data collection, aggregation, quantitative & qualitative analysis & reporting of trends & unusual occurrences by key area, severity, location/dept & job; identification of performance gaps & improvement opportunities; utilization of standardized classifications/definitions to categorize reported incidents & causal factors
- Directs & manages the risk mgmt/liability reporting process, including quarterly & ad hoc reports presented to Med center committees, Service Area Leaders, Regional Leaders, national KP depts or boards, regulatory agencies & other organizations
- Directs & manages the establishment & effective functioning of the Risk Mgmt/Patient Safety Committee at each Med center by providing facilitation, reports, data analysis direction for investigations & special projects, consultative services/expertise, coordinating follow through & evaluation of performance improvement plans designed by the Committee
- Meets regularly w/ the Exec Director, Med Director, Med Group Admin & others to review legal claims & risk mgmt data, identify systems issues & take appropriate actions to resolve & prevent recurrence of identified issues
- Directs & manages the risk mgmt education, training, communications process/services by coordinating risk mgmt education/training programs for Hospitals/Health Plan & SCPMG providers
- For more details, refer Job Description

Qualifications:

Basic Qualifications:
- Substantial (usually seven (7) years) experience in risk management with in an acute care medical center with minimum three (3) years in a supervisory/management role, including experience in planning, implementing, and evaluating risk management programs.
- Bachelor's degree in nursing, health services administration, public or business administration or public health required
- Master's degree in one of the aforementioned fields preferred
- Certified Professional in Healthcare Risk Management (CPHRM) required or certification obtained within one (1) year of hire date
- Current and valid licensure as a Registered Nurse issued by the California Board of Registered Nursing preferred
- Ability to demonstrate knowledge of governmental and regulatory standards/requirements/guidelines related to risk management; medical malpractice, tort principles and proceedings
- Ability to demonstrate knowledge of, and utilize the principles, practices and techniques of patient safety, and risk management, including risk identification, assessment, audit design, analysis, treatment and evaluation of risk management processes and systems (including Root Cause Analysis and Failure Mode and Effects Analysis); quantitative and qualitative statistical analysis; hospital and outpatient medical care delivery; quality management/improvement principles, methods and techniques
- Demonstrated ability to utilize effective oral and written communication skills
- Demonstrated ability to utilize consulting, project management and leadership skills such as coaching/mentoring, as well as interpersonal skills such as facilitation, negotiating, and influencing
]]> Sun, 11 Mar 2012 16:00:00 GMT 2239792-Fontana-Compliance,-Privacy,-and-Regulatory Job Location: Oakland or Pasadena

- Design, develop, test, debug, maintain and document automated logic used to assemble written health care contracts. This includes analyzing input data for quality and consistent mapping to contract language output.
- Monitor for errors trapped by the automated logic in production.
- Plan and coordinate change process for automated contract language.
- Serve as a liaison and coordinate activities with sales and account management operations and group contracting operations.
- Analyze business processes to identify functional requirements and technical specifications.

Preferred skills\qualifications:
Primary programming language is Author (aka Aurora, AuroraDS, IdWorkstation, Mosaic 2000, Oracle iStream Author) which can include SQL (structured query language). Editor is MS Word. Advance MS Word skill and experience is highly preferred.
Kaiser Foundation Systems contracts and benefits data
Kaiser Foundation Systems contracts processing at CSC
Oversight on or maintaining automated batch production environment.
MS SQL Server.
Other programming languages and applications for development, testing, and documentation processes:
o MS Access (queries and macros)
o VisualBasic (advanced macros)
o MS DOS batch
o Starteam
o Lotus Notes
o Remedy

Qualifications:

Basic Qualifications:
Minimum: Bachelor's & 5-8 yrs of applicable work experience
Experience with analytic manipulation and interpretation of large databases requires.
Three or more years of analytic consulting experience, health experience preferred.
Very strong analytic and critical thinking skills, writing skills, communication skills, consulting skills, and ability to work within a team.
Ability to express complex analytical and technical information to senior management or to audiences with clinical training. Must be an independent self-starter.
Proven ability in handling confidential data appropriately. Working well in diversified team structure.
Influential and effective in both written documents and verbally in formal presentations
Is recognized as an expert in at least one quantitative and/or qualitative method (e.g., methodology, research design, clinical content, or operational expertise as appropriate)
Able to recognize and develop plans to address the competing client expectations of executive and facility leadership
Microsoft Office skills required.
Experience with SQL and macros preferred.
Thorough knowledge of policies, practices and systems.
Complete understanding and application of principles, concepts, practices, and standards.
Full knowledge of industry practices.
Broad application of principles, theories, and concepts in applicable discipline, plus working knowledge of other related fields.
Knowledge of applicable systems to support contract production systems preferred.]]> Tue, 06 Mar 2012 14:00:00 GMT 2232599-Oakland-Compliance,-Privacy,-and-Regulatory
Basic Qualifications:
- Bachelor's degree or equivalent experience in Health Care Administration, or Business or Public Health Administration required
- Substantial experience (10+ years) of progressively responsible compliance/regulatory/quality management experience with minimum 3+ years in a senior leadership/executive role.
- Demonstrated ability to determine key business/compliance issues and develop appropriate actions plans from multi-disciplinary perspectives.
- Demonstrated management skills, including working with varied levels of staff through Senior Leadership, budgeting, delegation, staff development, and resource allocation and planning, and performance assessment skills.
- Outstanding communication skills with the ability to communicate persuasively and effectively (written and oral) to a wide range of internal and external customers.
- Demonstrated expertise in project management, analytic problem solving and negotiating.
- Demonstrated ability to lead professionals and manage through influence and collaboration.
- Strong working knowledge of federal and state laws and regulations related to health care and managed care organizations.
- Must be able to work in a Labor/Management Partnership environment.


Preferred Qualifications:
- Certification in Healthcare Compliance (CHC) preferred.
-Masters, law or related degree strongly preferred.

Qualifications:

Essential Functions:
- works with the VP Revenue Cycle, business and clinical leadership, and regional and national compliance leadership to develop a comprehensive, integrated business risk management/compliance plan and to create a common vision, strategy, and feedback loops for managing business risk within the revenue cycle organization.
- Works with the revenue cycle, business, and clinical leaders to develop and execute on-going strategies and tactics to ensure compliance readiness at all times within all areas of the revenue cycle organization.
- Collaborates with legal, compliance, internal controls, and SOX leaders at the national and regional levels to align regulatory requirements, processes, audit functions, policies, procedures, and strategic initiatives.
- Maintains a working knowledge of relevant third party payer contracts, accreditation standards, and regulatory trends, and industry practices that may impact the revenue cycle organization. Develops strategies to mitigate adverse impacts, and to leverage opportunities with respect to relevant trends, and changes, etc. Works collaboratively with the executive leadership, local leadership and the medical group leadership to integrate these changes into operations.
- Collaborates with regional and national compliance, SOX, quality, and internal audit departments to develop an integrated annual audit plan and directs the revenue cycle internal audit function. Develops programs to monitor, identify, and provide feedback to revenue cycle operational leaders on revenue cycle compliance problems and risks.
- Represents the revenue cycle organization in regulatory review forums/committees providing subject matter expertise on the potential impact of proposed changes in state and federal legislation, accreditation, and regulatory requirements (including health care reform) to the revenue cycle organization.
- Serves as a subject matter expert and advises clinical and business leadership on issues relating to regulatory compliance, health reform, and accreditation standards.
- Monitors state and national trends and regulatory changes in health care delivery. Identifies potential issues/risks to the revenue cycle organization and alerts senior leaders to changes/issues/risks on the horizon.
- Monitors the FAC Org system to ensure a highly level of integrity in all data elements.
- Works collaboratively with the revenue cycle leadership to develop educational programs for regional departments, and service areas to ensure compliance with regulations, accreditation standards, and organizational policies and procedures.
- Develops, and manages a compliance performance dashboard with leading indicators designed to identify areas of risk, and opportunities for improvement and monitors corrective actions designed to ensure compliance mandates are achieved timely; escalates issues; and reports performance to business and clinical leadership.
- Manages operating expenses within budget, and seeks opportunities to improve efficiency and reduce costs.
- Develops and executes an integrated communications plan to effectively engage and inform key stakeholders of relevant changes/updates to regulations, and accreditation standards to ensure success of key business strategies and operating areas.
- Establishes a plan to develop leadership capabilities, and employee engagement within the revenue cycle compliance community and create a culture that achieves high performance and professional integrity.
- Collaborates with the Regional Compliance Office to set strategic direction in responses to regulatory and accrediting agencies on surveys, audits, and incidents of non-compliance, errors, and omissions; communicates issues to appropriate stakeholders, and escalates issues to senior leadership; and works with revenue cycle, and business, and clinical leaders to address/mitigate risks to the organization.
]]> Thu, 01 Mar 2012 14:00:00 GMT 1681224-Oakland-Compliance,-Privacy,-and-Regulatory
Essential Functions:
- Project Planning: Identifies accountabilities for local /regional compliance program and consulting staff.
- Develops Compliance work and Audit plans.
- Collaborates in the development and completion of annual risk assessments.
- Takes complex ideas and input to develop/create project plans & strategies in support of established approach, goals, & time frames.
- Participates on and may establish compliance related committees/work groups to cultivate and reinforce appropriate group values, norms and behaviors.
- Leads compliance-related projects. Identifies & manages internal/external resources and agency relationships.
- Investigations: Performs routine & non-activities utilizing various compliance tools, databases and software applications. Performs complex analyses to identify potential compliance issues and areas of compliance requirements.
- Collaborates with other functional areas in investigating potential compliance issues.
- Develops investigation project plans.
- Independently or in collaboration, conducts fact finding interviews and summarizes investigational findings and recommendations.
- Collaborates with clients to determine simple corrective action plans appropriate to substantiated allegations and investigation findings.
- Validation: Participates and may lead in audits on scope of practice, licensing, site of service and other identified areas at risk for compliance violations.
- Consults in the development of Corrective Action Plans for identified compliance risk, monitors completion and periodically validates operational sustainability.
- Reviews compliance programs and content, including designing and conducting risk assessments and/or audits, and investigating instances of reported non-compliance.
- Assists with determining impacts of implementation of new regulations and statutes and required notifications, changes, and training.
- Communicates required changes, develops tools to assess risks, and leverages existing workgroups/etc. to facilitate required changes.
- Researches and stays abreast of regulations and statutes exhibiting extensive knowledge on a wide variety of clinical and non-clinical compliance issues.
- Implementation: Identifies and implements OIG compliance requirements; conducting related analyses.
- Assesses & synthesizes complex information to develop new solutions to existing alternatives.
- Creates, develops & revises basic & complex compliance standards, policies and procedures, including but not limited to privacy and security, fraud, waste and abuse, non-retaliation, disciplinary action, vendor relations etc.
- Monitors compliance adherence, reporting results to all levels of the organization.
- Influences management and staff to ensure compliance and reporting on compliance efforts and programs.
- Develops and/or conducts compliance and ethics training.

Qualifications:

Basic Qualifications:
- 5-8 years of heath care compliance, health care operations (quality, risk, etc.), audit, finance, project management, regulatory or public policy development, investigations, information security, or insurance/health plan governance experience.
- Bachelor's degree or equivalent experience.
- Masters degree in Health Care Administration, Business Administration, Finance, Economics, Operations Research, Public Health or other Health Care related field preferred.
- Certified in Healthcare Compliance (CHC) or other accredited compliance certified.
- Thorough knowledge of compliance principles, theories, and concepts.
- Thorough knowledge of health care compliance policies, programs, practices, systems, related compliance issues. Thorough knowledge of the elements of an effective Ethics and Compliance program and broad knowledge of health care industry practices and standards including both federal, state regulations and accreditation standards.
- Excellent Skills in written and verbal communication, meeting facilitation, presentations, analysis, collaboration, project management, decision making and stewardship.]]> Sun, 26 Feb 2012 14:00:00 GMT 2203283-Oakland-Compliance,-Privacy,-and-Regulatory Kaiser Permanente
Oakland or Pasadena, CA

Researches, plans, implements, and monitors a broad portfolio of compliance systems and initiatives to enable organizational compliance with all applicable Federal, state, and local regulations/laws, as well as overseeing the protection of organizational assets. On an on-going basis, researches and interprets regulations and laws to establish compliance standards, and may develop and/or deliver training and communications/change management relative to new standards. Assesses organizational systems (both physical and process or data related) to determine gaps in compliance and determine opportunities for remediation. Advises the organization on all compliance matters. May investigate violations of compliance policy, laws, regulations, etc. or conduct on-going monitoring and reporting to ensure remediation. May be responsible for project management relative to new compliance initiatives, products, or annual processes.


Qualifications:

Basic Qualifications:
- Required: Eight (8) to twelve (12) years of heath care compliance, health care operations (quality, risk, etc.), audit, finance, project management, regulatory or public policy development, investigations, information security, or insurance/health plan governance experience.
- Four (4) year or clinical degree
-Experience with interpreting Medicare laws, regulations, memorandums and manuals and ability to identify and partner with business to communicate impact and compliance expectations
-Familiarity with Medicare Advantage, 1876 Cost, and Part D reimbursement laws and regulations as wells as hospital Medicare and Medicaid Cost Reporting
-Specific knowledge of at least one of the following Medicare reimbursement and finance topics isrequired: Medicare Advantage and Part D Bids, Part D payment calculations and risk corridors, HMO Cost Reports and Hospital Cost Reporting.
-Ability to lead and manage operational and tactical aspects of multiple projects at the same time
-Plans, executes, and finalizes projects according to strict deadlines
-Ability to collaborate with multiple functions and departments, across various levels of the organization
-Strong critical thinking, problem solving, and oral and written communication skills
- Advanced knowledge of health care compliance policies, practices, and systems.
- Contributes to the development of compliance principles, theories, and concepts.
- Broad knowledge of health care industry practices and standards.
- Ability to draft and revise documents including policies, standards, analyses, and reports.
- Strong Project management skills
- Advanced knowledge of health care and related compliance issues.

Preferred Qualification
Experience with integrating compliance within system/application implementations preferable]]> Tue, 24 Jan 2012 14:00:00 GMT 2121549-Oakland-Compliance,-Privacy,-and-Regulatory Essential Functions:
- Serves as the primary contact for all regulatory agencies: Provides consultative services to all KFH/P and SCPMG departments and services regarding intent of regulations and means to maintain compliance.
- Keeps abreast of changes in legislation and requirements related to regulatory accreditation and licensing issues. May maintain the Service Area Administrative Policy Manual.
- Assures continuity and consistency in compliance with regulatory issues across the organization by evaluating the impact of specific issues. Collaborates with appropriate departments to develop and implement corrective action to minimize negative impact and maximize learning.
- Identifies key accreditation, regulation and licensing issues and defines areas for improvement.
- Relays internal/external communication of information related to accreditation, regulation and licensing. Prepares for surveys and inspections for all regulatory agencies.
- Maintains relationship with representatives of regulatory agencies.
- Collaborates and coordinates with departments on any implementation and evaluation of legislation affecting the Service Area.
- Provides overall staff support to the Accreditation and Licensing Committee such as to coordinate activities and agenda, to manage meeting minutes and action plans, and to provide research analysis and recommendations for issues.
- Develops and monitors annual budgets for all areas of responsibility.


Qualifications:

Basic Qualifications:
- Bachelor's degree, or equivalent experience in Health Care Administration, Public Health, nursing or other related field. Master's degree preferred. Clinical experience and clinical operations management preferred.
- Significant experience in health care (usually 5 years).
- Working knowledge of federal and state laws and regulations such as JCAHO, NCQA, Knox-Keene Act, Federal HMO Act, Health Care Financing Organization (HCFA), CMRI, Public Employees Medical and Hospital Act, applicable MediCal and Medicare regulations and rulings, and California Medical Review.
- Demonstrated experience in adult education and motivational theories, statistical analysis and quality management process.
- Excellent oral and written communication skills.

Preferred Qualifications:
- Master's in Health Care Administration or related field.
- Knowledge of Title 22 requirements, knowledge of V Surgery Electronic Surveillance Program, strong PC skills.
- Experience inleading change.
- Experience in staff education and strong communication and presentation skills.]]> Sun, 31 Jul 2011 16:00:00 GMT 1631300-Los-Angeles-Compliance,-Privacy,-and-Regulatory