The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
This is a remote position. Must reside in California preferably in our service areas.
At this time, the Health Plan does not sponsor visa. Candidates must have legal and valid work authorization, Green Card, or U.S. citizenship.
What You Will Be Doing:
Under general supervision responsible for coordination, assessment, research, analysis, maintenance and auditing of key compliance matters.
Essential Functions:
- Supports the development and renewal of state contracts and contract amendments, including coordination, verification, writing revisions of the EOC and submitting to the state.
- Conducts or assists in conducting risk assessments of HPSJ’s business practices and determining areas of exposure; recommends mitigation plans as needed.
- Conducts research and analysis on contractual and regulatory requirements with respect to HPSJ and delegated vendors.
- Maintains the compliance audit program, including schedules, standards, processes, reports and tools in close collaboration with the Compliance management.
- Conducts and coordinates routine and ad-hoc internal and external audits and identifies gaps that require corrective action plans.
- Coordinates or manages implementation of internal and external corrective action plans, monitoring progress and completion, coordinating interviews and document gathering; escalates as required.
- Provides guidance to internal and external stakeholders to ensure understanding and compliance with regulatory, contractual and accrediting requirements, and organization policies and procedures.
- Leads the compilation and tracking of deliverables; reviews deliverables for accuracy and facilitates corrections; obtains appropriate approvals and submits deliverables according to timelines.
- Evaluates financial impact of identified compliance issues, and reports findings.
- Develops and maintains routine and ad hoc Compliance Reporting, including but not limited to detailed and summary level reporting via written interpretation of analytical results to present to internal and external stakeholders.
- Enters and maintains data, information, documents and files according to standards, including but not limited to compliance software.
What You Bring:
Knowledge, Skills, Abilities and Competencies
Required:
- In-depth knowledge of federal and state regulations and standards, including False Claims Act as it relates to compliance in health care.
- In-depth knowledge of managed care health plan functions and interactions as they relate to compliance.
- In-depth knowledge of contracting regulations and best practices.
- Basic knowledge of ICD-10 and CPT coding and medical terminology, and industry standard payment practices.
- In depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
- Strong analytical skills, including the ability to perform routine analysis, using identified data, information and/or issues, and provide recommendations.
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- In-depth knowledge of basic data analysis tools and techniques, with ability to analyze and interpret data.
- Strong problem-solving skills, with the ability to identify and resolve problems of moderate complexity.
- Strong research skills with the ability to identify and review complex materials to develop and evaluate options and propose solutions.
- Strong organizational and project management skills, with the ability to prioritize and complete a variety of tasks and prioritize work of others.
- Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
- Strong oral and written communication skills with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of HPSJ; the ability to effectively explain complex information and document according to standards.
- Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.
- Time management: Uses time effectively and efficiently; values time; concentrates his/her efforts on the more important priorities; can attend to a broader range of activities; meets deadlines.
- Strong leadership skills, with the ability to influence without authority, establish direction, build alliances and motivate others.
- Commitment to and ability to facilitate the adoption of HPSJ’s strategy, vision, mission and values.
- Strong mathematics skills, including the ability to calculate ratios, perform simple algebra and statistical formulas.
- Intermediate skills in Word, Excel, Power Point, Visio and Project.
- Ability to speak and be understood in English.
- Ability to handle confidential information with appropriate discretion
Preferred
- Basic skills in reporting software, such as Tableau, with ability to present data in consumable formats such as charts and graphs.
What You Have:
Education and Experience
Required
- Bachelor’s Degree; and
- At least three years of experience reading, analyzing and interpreting State and Federal laws, rules and regulations; or
- Equivalent combination of education and experience
Preferred
- Experience as a Compliance Data Analyst in a Medi-Cal managed care plan
Licenses, Certifications
Preferred
- Certified in Health Care Compliance.
What You Will Get:
HPSJ Perks:
- Robust and affordable medical coverage including HMO and PPO plan options
- Employee Wellness Program promoting physical, mental, and financial well-being
- Dental and vision plan with multiple provider choices
- Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays)
- CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan
- Two flexible spending accounts (FSAs)for healthcare and dependent care expenses
- Employer-Paid Term Life and AD&D Insurance
- Employer-Paid Disability Insurance
- Employer-Paid Assistance Program (EAP)
- Health Advocacy to help you navigate medical care and benefits
- Voluntary supplemental benefits including medical, legal, identity theft protection
- Online discount mall
- Tuition reimbursement
- Remote work contingent on business needs and company guidelines
- A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do
Physical Demands
Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds.
Emotional/Psychological Demands
Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations.
Work Environment
Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards.
Important Notice: The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.
