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Director Compliance Operations Silver Spring MD Silver Spring, MD



Description

This leadership position is responsible for the promotion, direction and oversight of the following regional compliance activities: administrative and care delivery compliance functions within the Health Plan; compliance training and awareness; fraud, waste and abuse prevention and detection; and compliance investigations performed by staff in the MAS Regional Compliance Office. This position shall be responsible for addressing compliance issues and for acting as the primary liaison to the following areas or entities: KP Information Technology (KPIT), KP Health Connect (KPHC) Team, National Special Investigations Unit (NSIU), National Facilities Services (NFS), Finance, Patient Financial Services (PFS), Revenue Cycle, Health Information Management Services (HIMS) and Provider Relations. This position and the Regional Compliance Officer (RCO) act as primary regional compliance liaisons to PO Legal and Labor partners to resolve complex matters or issues. This position shall represent the RCO on national and regional committees and forums as assigned with the authority to act on behalf of the RCO. In addition to these primary responsibilities, this position also provides supervision, and support for compliance staff responsible for fraud control programs (including the Medicaid program integrity program), care delivery compliance activities, revenue cycle compliance and facility compliance.


Essential Responsibilities:
- This position is responsible for the guidance and oversight of compliance efforts, partnering with regional leaders with operational accountability undertaken in ,many administrative departments/functions.
- In conjunction with Regional leadership team, plans strategic direction and organization of compliance activities in primary areas of responsibility in region. This position is responsible for partnering strategically with leadership of these areas, as well as with NCO, to address regional compliance risks and determine how to address them in light of regional/national business objectives and limitations. Build and maintain collaborative partnerships with Mid-Atlantic Permanente Medical Group (MAPMG), service area administrators and clinical specialty leadership and labor representatives to assure the success of compliance objectives and successful resolution of compliance incidents which arise.
- Objective: Ensure Compliance is engaged, aware of and addressing current or potential compliance issues throughout the region through partnership with each of these areas.
- Direct. and/or coordinate all investigations performed, in whole or in part, by Regional Compliance staff, to assure that the investigatory work is conducted in a consistent, professional and timely manner. This responsibility includes, but is not limited to, investigations relating to privacy or security violations, internet misuse, specified KP workforce personnel issues, facility, pharmacy fraud, and claims fraud. This responsibility also includes the oversight of all work product/documentation required resulting from said investigations and oversight of timely investigation case and CAP closures. This position is also responsible for timely and accurate resolution of Hotline complaints. Also conducts special investigations at the request of senior leadership.
- Objective: To ensure that all complaints and corrective actions area addresses in a timely and consistent way, and to limit misuse of KP assets data (including PHI), and to control fraud.
- Responsible for the overall leadership and strategic direction of the compliance program staff responsible for investigations, , fraud control care delivery compliance, and training and awareness. Part of this responsibility is to ensure efficiency and effectiveness of compliance staff efforts in assigned areas, and to ensure that performance targets are set and clearly communicated. Directly responsible for the management and direction of the,
- Care Delivery Compliance Program Manager, Integrity and Fraud Control Manager, the Training Coordinator, Compliance Coordinators, and other staff as assigned. Promotes a culture of performance management, with identification of key drivers of performance and monitoring of performance for staff under the leadership of this position. Provide professional and skill development for staff, managing performance by providing feedback and developing and implementing development/corrective action plans.
- Objective: To assure that staff perform to peak capacity and to provide learning and growth opportunities to staff. Also, to bring value to the organization through managing performance and ensuring that the limited staff resources are focused on the goals of the region and the national program.
- Direct the development of a robust fraud control plan in the region, leveraging the regional Fraud Control Committee and the compliance working subgroups as necessary, to create and deploy such plan. This role will require close collaboration with NSIU leadership and with KPIT Data Security and NFS to assure consistency of objectives and approach. Collaborates with key administrative departments and delivery system to identify necessary controls. Also responsible for the development of a comprehensive regional compliance program to identify, address and remediate provider claims fraud, working with both national and regional resources and claims fraud detection resources.
- Objective: To identify and address fraud throughout this region and to champion those changes necessary to meet this regulatory expectation.
- Champion's process optimization within Compliance, and upon the request of senior leadership staff in the region, leads process optimization efforts in key areas of organization. Identifies areas of risk for compliance deficiencies in those departments or functions for which this position is responsible, and develops, implements, tracks and reports on work plans for correction and adherence to policies and standards. (Intervention and process development based on identified deficiencies from HIPAA or Fraud Control audits/surveys or investigation findings which may include identification of needed policy development and education, procedures and regulations interpretation and application.) Directs, develops and implements an effective Compliance awareness education program relating to HIPAA, fraud/waste/abuse, and EEO for KPMAS staff.
- Objective: Assessment of risk areas and driving process improvement through optimization, both within Compliance and the organization as a whole.
- Serve on numerous cross-functional and special projects and committees involving key/senior managers and directors within MAS Health Plan, Program Offices and MAPMG. Primary authority to drive compliance objectives on behalf of the regional compliance office. Represent Compliance and Regional Compliance Officer in meetings, interviews, negotiations, hearings and task forces, either internal or external to KP. Also, working with RCO, is primary compliance liaison to labor and Program Office Legal to address complex compliance related issues.
- Objective: To drive compliance objectives and to represent RCO at leadership level both locally and nationally as needed.



Qualifications:

Basic Qualifications:
Experience
- Minimum ten (10) years of professional experience in a health care compliance setting with at least seven years in a compliance management role or as a health law attorney required.
- Minimum eight (8) years of experience in staff management required.
- Minimum eight (8) years of experience conducting or managing complex investigations required.
- Minimum eight (8) years of experience in addressing clinical or physician compliance-related matters required.
Education
- Bachelor's degree in health care related field.
License, Certification, Registration
- HCCA Certification required within twelve months of hire into position.

Additional Requirements:
- Excellent written and oral communications required.
- Ability to interact with IT professionals, in-house and outside counsel, law enforcement and care delivery professionals required.
- Knowledge of HIPAA, Stark, and False Claims Act required.
- Demonstrated ability to work independently and to motivate people to achieve shared goals is required.
- Results-oriented, analytical and creative thinker with the highest level of personal integrity required.

Preferred Qualifications:
- Masters preferred.

- Licensed RN or other health care discipline licensure preferred.
- Coding certification preferred.
- Knowledge of state statutory and regulatory requirements and coding preferred.



Primary Location: Maryland,Silver Spring,Regional Offices-Garrett 11921 Bournefield Wy. St

Scheduled Hours (1-40): 40

Shift: Day

Working Days: Mon-Fri

Schedule: Full-time

Job Type: Standard

Employee Status: Regular

Employee Group: Salaried, Non-Union, Exempt

Job Level: Director/Senior Director

Job: Legal / Government Relations

Public Department Name: Regional Compliance


External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.

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