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Compliance Specialist III, South San Francisco, CA

Organization: Health Plan of San Mateo
Category: Professional
Location: South San Francisco, CA
Date Job Posted: February 5, 2020
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The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Compliance Specialist III. The Compliance Specialist III will assist in the development and implementation of processes for the organization and department. Monitors business area activities in response to external audit for compliance with applicable rules and regulations. Ensures operating policies, procedures and related documentation stays current when regulations change. Responds to inquiries from regulatory agencies and completes required compliance documentation.

The essential duties and responsibilities will include the following:

  • Manages plan participation in external audits conducted by DHCS, DMHC, CMS and NCQA by serving as primary contact and coordinator. Identifies appropriate business owners, disseminates requirements, coordinates communication, and validates appropriateness of deliverables for these audits.
  • Leads audit preparation sessions for external audits by ensuring business area representatives are prepared to respond to audit interview sessions, are familiar with audit tools, and can speak to ongoing and corrected business activities.
  • Leads the corrective action planning process by working with business areas assigned corrective action plans, vetting proposed corrective actions by business areas, and successfully working with regulatory agency representatives to get proposed corrective action plans approved.
  • Analyzes plan performance in external audits to identify areas of improvement in audit preparation, audit response, CAP design and submission and related activities. Works with the Chief Compliance Officer to gain consensus and to lead implementation of approved efforts.
  • Promotes department drive for continuous quality improvement by creating, analyzing and critiquing proposed and ongoing department initiatives. Uses tools made available by the organization to track, manage and provide input into department goals, objectives, projects and ideas.
  • Manages process improvement process for Annual Compliance Training for staff and Commissioners. Analyzes feedback data to identify opportunities to improve training offerings.
  • Supports the Compliance Program Manager by designing, documenting and implementing process improvement initiatives within the department.
  • Supports Compliance Program Manager in leading HPSM’s maintenance of NCQA accreditation. Creates and maintains tools to identify and close performance gaps against NCQA standards and coordinates improvement activities. Coordinates communication efforts related to NCQA readiness.
  • Assumes primary responsibility for HPSM’s policy and procedure lifecycle, including maintenance of policy and procedure repository, quality of documentation, and identifying opportunities to improve processes and submitted policies and procedures.
  • Supports and when directed, leads HPSM’s Policy and Procedure Committee and Audit Work Group.
  • Maintains Compliance software or ensures tools supplied by HPSM are designed to maximize usefulness to the department.
  • Perform other duties as assigned


Education and Experience:

  • Bachelor’s Degree in Business Administration, Health Care Management or Public Policy required.
  • Minimum four (4) years of managed care or health care experience preferably with Medicare/Medi-Cal experience
  • Experience with quality improvement/process improvement techniques preferred.
  • Previous project/program management experience preferred.

Knowledge of:

  • Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint
  • Proficiency with project management software, including Microsoft Project, Confluence or similar tools
  • Internal auditing, quality assurance, and/or quality improvement processes
  • Change management, process improvement and redesign
  • Knowledge of accrediting/regulatory body requirements

Ability to:

  • Work cooperatively with others.
  • Work as part of a team and support team decisions.
  • Communicate effectively, both verbally and in writing.
  • Adapt to changes in requirements/priorities for daily and specialized tasks
  • Demonstrate strong analytical and research skills
  • Communicate effectively, orally and in writing

Compensation and Benefits

Starting Compensation Range: - Depending on Experience

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage. Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits. Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.

How to Apply

Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: or via fax: (650) 616-8039. File by: Continuous until filled. The Health Plan of San Mateo is proud to be an Equal Opportunity Employer and encourages minority candidates of all backgrounds to apply.

Submissions without a Cover Letter and Salary Expectations may not be considered.

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