Medical Management Medicare Compliance Liaison (CA: Woodland Hills)
Location: Woodland Hills California
Description: Health Net, Inc. - 4002 is presently looking of Medical Management Medicare Compliance Liaison (CA: Woodland Hills) right now, this position will be placed in California. More complete informations about this position opportunity kindly read the description below. Health Net, Inc. is a publicly traded managed care organization that delivers ma! naged health care services through health plans and government-sponsored managed care plans. Its mission is to help people be healthy, secure and comfortable. Health Net, through its subsidiaries, provides and administers health benefits to approximately 5.4 million individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as "Part D"), Medicaid, U.S. Department of Defense, including TRICARE, and Veterans Affairs programs. Health Net's behavioral health services subsidiary, Managed Health Network, Inc., provides behavioral health, substance abuse and employee assistance programs to approximately 4.9 million individuals, including Health Net's own health plan members. Health Net's subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-f! unded benefits programs.
For more information on Heal! th Net, Inc., please visit the company's website at
www.healthnet.com
.
JOB SUMMARY:
The Compliance Medical Management Liaison resides in the Medicare Compliance Department and oversees a wide range of compliance activities for an assigned business unit to assure operational and procedural compliance with legislative and regulatory requirements. This role works closely with the assigned business unit's Business Compliance Consultant, management team, change implementation team, and the Medicare Compliance Department to affect the company's regulatory compliance program.
Responsible for ensuring legislative and regulatory changes that affect the business unit are promptly identified and providing guidance and consultative support to the business unit in implementing requirements. The Compliance Medical Management Liaison conducts monitoring activities to define gaps, identify emerging compliance trends and detect potential risk ! areas. This role tracks and monitors the business unit's corrective action plans resulting from regulatory audits or identified compliance deficiencies and serves as the key point of contact between the Medicare Compliance Department and the business unit
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Communicate new and revised laws and regulatory guidance that affect the business unit and interpret/summarize the requirements. Collaborate with the business unit to review, analyze and oversee regulatory implementation project plans, including gap analysis, communication and training, action plan deliverables and development/revision of policies and procedures.
Consult with the business unit on developing and implementing compliance controls and quality measures.
Triage complex compliance issues, independently conducting internal/external research on topics, as needed.
Support business unit in establishing policies, procedures and best ! practices that promote compliance with applicable laws and regulations.! Perform a compliance review of proposed statements of policy and procedures
Monitor business unit compliance performance to validate business unit self-audits. Proactively test policies and procedures against regulatory requirements. Report results to business unit and Medicare Compliance Department.
Provide input to business unit in development of corrective action plans in response to identified deficiencies, track progress, and communicate status of corrective actions to the business unit and Medicare Compliance Department.
Provide input and guidance in development of advertising campaigns and member materials to ensure compliance with regulatory requirements.
Monitor business unit's escalation activities to ensure potential compliance risks and suspected or confirmed compliance issues are escalated to business unit management and Compliance Officer.
Participate in business unit meetings to provide compliance input and reinfo! rce applicable compliance requirements.
Monitor business unit completion of all required compliance training.
Consult/Provide input to the Business Compliance Consultant of the assigned business unit for the following compliance activities:
Implementation of regulatory changes that span multiple departments.
Development and maintenance of a consistent process for identification and escalation of issues and supporting tools; may act in a consultative capacity in the implementation of a tool(s) for maintenance of mapping requirements/regulations to policies and procedures (P&Ps) and owners (i.e. CFR owners).
Development, implementation, communication and training on new/updated policies and procedures, including appropriate connectivity and handoffs for P&Ps documenting processes that span multiple departments.
Compliance of business unit's First Tier, Downstream and Related Entities and delegated providers/groups, as appl! icable.
Development and maintenance of operational risk assess! ment and auditing and monitoring work plan.
Identify and develop key controls and compliance monitoring and surveillance activities.
Proper documentation of evidence of compliance.
Participate with business unit leadership and Business Compliance Consultant in development, monitoring and reporting of compliance metrics and overall performance dashboard. At the direction of the Medicare Compliance Department, work with Business Compliance Consultant to validate compliance metrics are appropriate/sufficient from a compliance perspective.
Under the direction of the Medicare Compliance Department, prepare the business unit/functional department for regulator audits
Participate in and support other components of the company's compliance program, such as Privacy, Data Security, Code of Business Conduct and Ethics, Fraud Waste & Abuse, etc.
Promote a positive compliance and ethics environment.
Qualifications
REQUIREMENTS:
Education:
BSN or BA degree in Business Administration, Finance or related field
Certification/License:
Active, valid & unrestricted state of CA Registered Nurse license required, if an RN
Certification in Healthcare Compliance (CHC) a plus.
Experience:
Minimum two years clinic or health care experience
Minimum three years managed care experience
Five to ten years experience in progressively broad and challenging roles in one or more healthcare Medicare Management areas.
Prior experience in a compliance-related role highly desirable.
Applied knowledge and experience in Medicare Managed Care, also known as Medicare HMO Advantage.
RN preferred
Knowledge, Skills & Abilities:
Demonstrated advanced understanding of a Medicare Medical Management, requirements, processes, policies and procedures.
Thorough knowledge of regulat! ions as set forth by The Centers for Medicare Medicaid Services.
Demonstrated ability to work collaboratively in a highly matrixes environment and gain support of others to achieve desired compliance outcomes.
Confidently interact with associates at all levels of the company, including senior leadership.
Communicate skillfully to others, in both written and verbal communications.
Excel at managing multiple and sometimes competing priorities.
Excellent organizational analytical, process and writing skills
OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
WORKING CONDITIONS:
The following section describes the general physical requirements for this position. Please note that 'constant' refers to more than 81% of time; 'si! gnificant' refers to 40-80%; and 'moderate' refers to 20-40% of the time.
Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
Required to have hearing ability to rec! eive detailed information through oral communication.
Required! to have speaking ability to express or exchange ideas.
Constant concentration may be required on various subjects by listening, reading and thinking clearly.
Interaction with others may be required. May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions.
Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.
Constant computer usage including typing and/or eye strain.
Moderate repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
Significant phone usage; headsets may be required.
Constant sedentary work (desk bound or seated).
Constant reading is required! via computer screen and/or bound printed materials.
Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.
Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.
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If you were eligible to this position, please email us your resume, with salary requirements and a resume to Health Net, Inc. - 4002.
If you interested on this position just click on the Apply button, you will be redirected to the official website
This position starts available on: Sun, 01 Sep 2013 03:09:14 GMT
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