Kern Family Healthcare. The friendly face
Our Mission…Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system
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. This position should establish and maintain positive relationships with regulators, and become a resource for Kern Health Systems staff on regulatory issues.
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.
** 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. Report all suspected fraud and abuse to DHS and work with legal counsel on fraud investigative activities and corrective action.
** Act as liaison and contact point for contracting and regulatory agencies. Coordinate review and implementation of all regulatory All Plan Letters. Submits required materials in appropriate formats to appropriate agencies.
** Develop and submit an annual Master Audit Plan (MAP) to the CEO and CFO for review and approval prior to implementation.
** 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 HIPAA Officer and oversees staff education for HIPAA. 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.
** Complete other work-related duties as assigned by COO/CEO.
** Adheres to all company policies and procedures relative to employment and job responsibilities.
** Other duties as assigned
Bachelor’s degree from an accredited school or equivalent required. Master’s degree in business administration preferred.
Six (6) years of experience in legal and/or health care related field. Managed care experience with significant accounting and auditing experience desired.
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.
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.
- Pay Type Salary
- Travel Required Yes
- Travel % 10
- Telecommute % 0
- Required Education Bachelor’s Degree
- Kern Family Health Care, 2900 Buck Owens Blvd., Bakersfield, California, United States of America