Regulatory Affairs Specialist
Job ID 2022-2227 FLSA Status Non-Exempt
Under supervision and direction of the Regulatory Affairs Manager, this position assists in supporting the plan-wide HIPAA program and Fraud, Waste, and Abuse (FWA) program and acts as a liaison between the plan and our regulatory agencies. This position coordinates daily efforts between departments to conduct investigations into potential privacy or FWA related incidents, assess and mitigate risk as well as develop corrective action plans when applicable. This position supports the plan’s compliance program and assists in efforts to be compliant with applicable laws, regulations, and policies.
- Works independently using critical thinking and analytic skills to conduct privacy risk assessments and investigates privacy incidents or potential FWA related cases
- Uses all information gathered and/or evidence found during the investigation to determine the outcome of the investigation or escalates when appropriate to Regulatory Affairs Manager for a determination
- Based on determination of the case outcome works with or meets with departments to mitigate future risk and develop corrective action plans, when applicable
- Using EthicsPoint, manages privacy and FWA case load to ensure the timely submission of all regulatory reporting requirements as well as maintains complete and accurate documentation to support the outcome determination and/or findings for audit purposes
- Using the appropriate DHCS reporting form, drafts initial reports, updated reports and final reports and submits timely to the designated DHCS reporting unit
- Responsible for identifying trends and linking related cases to assist with trending patterns and maintaining accurate data for daily, monthly, quarterly, and annual privacy and FWA analytics
- Works directly with DHCS Privacy Officer to report privacy related incidents, provide updates upon request, ensure timely filing requirements are met for all reports and follows up on pending cases to confirm cases are closed with the DHCS Privacy Office.
- Works directly with DHCS Program Integrity Unit (PIU) and DHCS Audit & Investigation Unit (A&I) to report potential FWA related cases, provide case updates as new evidence is found, ensure timely filing requirements are met for all reported cases and follows up on pending cases to confirm cases are closed with DHCS PIU or A&I.
- Responsible for maintaining compliance training program, including:
- New hire compliance training,
- Annual compliance training – HIPAA, FWA, Code of Conduct, Compliance Plan as well as the testing and retention
- Conduct targeted department trainings – topics requested by departments and refresher trainings, or identified trends using privacy and FWA analytics - Distributes, collects and retains copies of completed compliance primers
- Responsible for managing the RAC Inbox and RAC Reporting Inboxes, including:
- Researching regulatory related inquiries and provide response to inquiries,
- Coordinating plan responses to DHCS adhoc requests, surveys or questionnaires
- Circulate DHCS guidance to appropriate stakeholders
- Works with departments on regulatory required submissions, assists with determining if governing agency’s approval is required, maintains a submission tracking mechanism, assists departments with additional information requests, provides department with final approval and maintains documentation of approval for audit purposes
SECONDARY DUTIES AND RESPONSIBILITIES
- Assists Regulatory Reporting Analyst in the collection of data and other input for recurring reports due to federal, state and other entities requirements
- Assists in compiling information into required format and performs quality check for accuracy
- Assists Regulatory Affairs and Compliance unit with the administrative functions to support unit meetings, workgroups, committees and/or projects - Other duties as assigned
Education and Experience
Bachelor’s degree in relevant field preferred, two – three (2-3) years of experience in the health care field, managed care experience preferred, with knowledge of the Knox-Keene, Medicare, Medi-Cal, and Healthy Families regulations; or an equivalent combination of education and experience.
Special Skills, Licenses and Certifications
Highly proficient in applicable business software applications including PC usage, Microsoft Word, PowerPoint, Excel, Project, typing speed of 30 wpm. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Performance Based Competencies
Excellent oral and written communication skills. Excellent organizational skills with ability to prioritize assignments, maintain effective filing systems, and meet deadlines. Ability to work under minimal supervision and exercise independent judgment. Diplomacy and tact in handling sensitive information regarding personnel affairs as required. Ability to interact with executives and vendors effectively, handling all assignments with efficiency. Must be able to handle multiple tasks and meet deadlines. Excellent judgment.
Work Environment And Physical Demands
Ability to use a computer keyboard and other business machines. More than 50% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying sizes, weighing up to 35 pounds.
All HealthPlan employees are expected to:
- Provide the highest possible level of service to clients;
- Promote teamwork and cooperative effort among employees;
- Maintain safe practices; and
- Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.