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Director of Compliance & Regulatory Affairs, Bakersfield, CA


Organization: Kern Health Systems
Category: Director
Location: Bakersfield, CA
Date Job Posted: June 30, 2021
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Director of Compliance & Regulatory Affairs

Kern Family Health Care, 2900 Buck Owens Blvd., Bakersfield, California, United States of America Req #1584

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).

Definition

The Director of Compliance and Regulatory Affairs serves as Kern Health Systems Compliance Officer to ensure organizational compliance with all regulatory requirements, contract requirements, and company policy and procedures, and for conducting, coordinating and reporting audit and investigative activities for the purpose of preventing and detecting fraud, abuse, and waste. The Director of Compliance and Regulatory Affairs oversees and communicates all assigned compliance activities and programs, as well as plans, implements, and monitors the compliance program. This position should establish and maintain positive relationships with regulators and become a resource for Kern Health Systems staff on regulatory issues.

Distinguishing Characteristics

This position is responsible for management, coordination and completion of activities related to regulatory requirements, contract compliance and fraud prevention and investigation for a Knox-Keene health maintenance organization (HMO). This position is responsible for reporting directly to the Chief Executive Officer and the Board of Directors on compliance issues when appropriate or required by the nature of the compliance issue.

Essential Functions

  • Directs the preparation of filings and plan amendments to the Department of Managed Health Care, Department of Health Care Services, and other regulatory agencies;
  • Review, evaluate, and report results of audits of all operational departments to ensure compliance with established policies, procedures and performance standards. Prepare reports of findings and make recommendations. Work with appropriate staff regarding development, approval and implementation of Corrective Action Plan (CAP) regarding audit findings;
  • Coordinates KHS participation in external audits by KHS operational department staff of delegated entities;
  • Assist with corrective action plans regarding external agency audit findings and report to Executive Staff and Department Managers;
  • Develop and implement policies and procedures to prevent and detect fraud, waste or abuse. Oversee the development and ongoing training for employees, members, providers and other suppliers of services regarding anti-fraud awareness;
  • Oversee all activities related to the detection, prevention, investigation and reporting of all potential fraud, waste and abuse. Act as the liaison between the Plan and appropriate regulatory agencies (e.g., DHCS, OIG, DOJ) for fraud and abuse issues. Work with legal counsel on fraud investigative activities and corrective action;
  • Act as liaison and contact point for contracting and regulatory agencies;
  • Oversees the review and implementation of all regulatory All Plan Letters;
  • Submits required materials in appropriate formats to appropriate agencies;
  • Develop with the Compliance Committee the annual Compliance Work Plan to submit for review and approval by the Board of Directors;
  • Responsible for maintaining KHS Policies and Procedures (P&P) and filing of updated P&Ps with appropriate regulatory agencies;
  • Ensure compliance with all regulatory agencies in accordance with State and Federal requirements;
  • Acts as the Plan Privacy Officer. Oversees HIPAA, FWA, and Compliance staff education with HR. Report plan HIPAA infractions to the State Privacy Officer and the Plan Contract Manager at DHCS;
  • Coordinate, prepare and monitor special projects and reports as required;

Other Functions

  • Complete other work-related duties as assigned by the CEO.
  • Adheres to all company policies and procedures relative to employment and job responsibilities.
  • Other duties as assigned

Employment Standards:

Education:

Bachelor’s degree from an accredited school or equivalent required. Master’s degree in business administration preferred. Certification in Healthcare Compliance preferred.

Experience:

Ten (10) years of experience in legal and/or health care related field. Managed care experience in Medi-Cal and Medicare highly preferred.

Knowledge of:

Managed care systems of a Knox-Keene licensed health maintenance organization (HMO). Understanding and interpretation of State and Federal regulations. Microcomputer applications: spreadsheet, database, and word processing.

Ability to:

Work independently and manage multi-task responsibilities. Maintain confidentiality, communicate effectively with KHS staff, providers, regulatory agencies and legal counsel; excellent written and verbal communication skills.

Other: Required travel up to 20%. Possession of valid California Driver's License and proof of valid State required auto liability insurance.

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

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