• Direct and effectuate CCH management policies practices
• Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements

Management

• Contribute to the management of CCH staff and CCH systemic development and success
• Discuss and develop CCH system policy and procedure
• Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary; hire. transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements
• Work with Labor Relations to discern past practice when necessary

Typical Duties

• Governance of the Health Plan's Fraud, Waste, Abuse (FWA) and Financial Misconduct Program (Program Integrity Program); Special Investigations Unit; to ensure that FWA and Financial Misconduct is actively administered , as delegated by the Chief Corporate Compliance & Privacy Officer
• Monitors operational management of the Health Plans' complaint, grievance, appeals and the fair hearing process received from members and care providers for program compliance in addition to trends and patterns through reports and data analysis
• Collaborates with the Chief Corporate Compliance & Privacy Officer to ensure that FWA is reported in accordance with federal, state and local requirements, as well as the guidelines in the Medicaid Managed Care regulations at 42 CFR SS438.608 and the CCH Managed Care Community Network (MCCN) Agreement with Healthcare Family Services (HFS)
• Implements and coordinates methods and programs that encourage workforce, employees and independent contractors to report issues related to noncompliance and potential FWA without fear of retaliation.
• Reviews health plan agreements, contracts, addenda, and other relevant documents, as needed.
• Aligns with operational management of the Health Plans' sanction/exclusion check to ensure that providers, management, workforce and independent contractors (where necessary) are screened against applicable Federal and state sanction and exclusion lists.
• Coordinates potential fraud investigations/referrals with the Special Investigations Unit (SIU), where applicable.
• Collaborates with other health plans, HFS, Medicaid Fraud Control Units (MCFUs}, commercial payers, and other organizations, where appropriate, when a potential FWA issue is discovered that involves multiple parties.
• Serves in a leadership capacity to develop the system-wide compliance program in conjunction with the Chief Corporate Compliance & Privacy Officer
• Collaborates with operational leadership to facilitate operational ownership of compliance
• Synchronizes system-wide compliance program materials and messaging to present a uniform approach .
• Oversees, directs, delivers, tracks, or ensures delivery of compliance training, both global and specialty, for employees, physicians, volunteers, students, vendors, and consultants
• Develops, assesses, evaluates, implements, maintains, and updates compliance policies and procedures to ensure adherence with the requirements
• Establishes a structured process for regulatory review, monitoring, and dissemination of information. Modifies policies, procedures, and projects to reflect changes in laws and regulations
• Develops and coordinates compliance projects with CCH system entities as delineated in the Compliance Program Annual Work Plan and perform prospective reviews in conjunction other personnel as deemed necessary, and as determined by the Chief Corporate Compliance & Privacy Officer
• Performs system-wide interviews with all key personnel to validate compliance with established policies and procedures and applicable regulations in conjunction with other personnel, as deemed necessary
• Prepares and analyzes a narrative description of the process or function under review In order to evaluate potential strengths and weaknesses and to determine the adequacy of the overall system to ensure compliance, as deemed necessary
• Develop reports upon completion of each compliance review, which details recommendations designed to correct any potential weaknesses or areas of non-compliance discovered during the review
• Perform Follow-Up reviews as generated by the Compliance Program Work Plan to ensure action plans have been adequately implemented
• Assure that Compliance Program reports are produced for the Chief Executive Officer, Board of Directors, and/ or the Audit and Compliance Committee of the Board of Directors, as directed by the Chief Corporate Compliance & Privacy Officer
• Establishes and administers a process for receiving, documenting, tracking, investigating, and taking action on all compliance concerns
• Perform compliance interviews and investigate reports of alleged non-compliance to determine the validity, nature and scope of the report in conjunction with the designated team members, as identified by the Chief Corporate Compliance & Privacy Officer
• Collaborates with operational areas to remediate concerns through action plans to correct potential weaknesses and assure ongoing compliance
• Develop Compliance Reports during the course of the investigation and subsequent to the completion of the investigation under the auspices of the Chief Corporate Compliance & Privacy Officer, and Legal Counsel if deemed necessary
• Maintains highest levels of confidentiality regarding all departmental operations - in communication both verbal and written and with the use of technology
• Ability to prioritize work with minimal supervision and use time effectively. Requires high degree of follow-through despite frequent interruptions
• Possess ability to work in a fast-paced environment, which requires handling multiple tasks at once

Reporting Relationships

Reports to the Chief Corporate Compliance & Privacy Officer.