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Years of Experience
Date Last Verified
Chief Compliance Officer, Care1st Duties: Responsible for executing and maintaining an effective corporate compliance and ethics program consistent with the Federal Sentencing Guidelines and industry best practices, and for implementing and maintaining the company’s Medicare (Medicare/MAPD) and Medi-Cal (Medi-Cal and Cal Medi-Connect (CMC)) Compliance Programs in accordance with applicable state and federal regulatory requirements and best practices. Functions as the company’s Medicare Compliance Officer and serves as the first point of contact for compliance matters related to the company’s Code of Conduct as well as Medicare/Medi-Cal contract compliance issues. Will report to the Senior Director, Care1st Compliance. Works with the company’s attorneys, business executives, and senior management on strategic planning activities to ensure the company’s continuing compliance with Medicare/Medi-Cal contract requirements, applicable federal and state laws, regulations, and agency guidance, and the Company’s Code of Conduct. Fosters and promotes compliance awareness throughout and partners with key business stakeholders to manage and mitigate compliance risk. Oversees implementation and maintenance of proper preventive, detective, and remedial controls, the documentation and execution of necessary compliance-related policies and procedures, training and educating the workforce on issues of compliance, implementing an effective compliance program, ensuring effective testing, auditing, monitoring, tracking and reporting, remediating control deficiencies, and non-compliance response and management. Will keep abreast of relevant industry standards and will support the business in maintaining compliance with existing, new and emerging state and federal laws, regulations, and contractual requirements. Ensures that appropriate documentation is maintained for all compliance activities. Provides regular reports to the company’s executives, Board of Directors, and Blue Shield of California (e.g., through reports to the Vice President, Chief Risk and Compliance Officer of Blue Shield of California) on the status of the company’s corporate Compliance & Ethics Program and Medicare and Medi-Cal compliance activities. The Senior Director, Care1st Compliance must be prepared to respond to questions from Executive Leadership and the Board of Directors as needed. Develops and manages the compliance program for Care1st’s Medicare and Medicaid lines of business; through oversight and monitoring activities, ensures regulatory compliance for all related federal/state laws and regulations. Lead team of compliance professionals to ensure robust and effective preventive, detective and remedial compliance controls throughout the company’s operations. Implement and execute effective training, communications and awareness programs to properly educate employees and business partners regarding compliance related legal requirements and responsibilities. Build and maintain effective relationships with all relevant internal and external stakeholders, including federal, state and local regulatory entities, Information Technology (IT), IT Security, Marketing, Finance, Customer Service, Human Resources, Employee Relations, Legal, and Internal Audit, among others. Compile clear, accurate and timely reports for senior management and the Board, as needed. This includes the proper investigation and inquiry reporting, tracking, closure metrics and accompanying analyses (e.g., trend and pattern identification). In consultation with appropriate legal counsel, assesses and communicates compliance impacts of laws and regulations to the appropriate departments in the company. Manages a set of metrics based on internal auditing, self-reporting & monitors the analysis of compliance metrics.
Qualification and Experience
Qualifications: JD Degree, MBA, or graduate degree in healthcare administration, or related field. CPA, CIA, CFE, CHC or CCEP certification preferred. 10+ years’ experience as a Compliance Officer in a healthcare/managed care environment overseeing government program compliance/administration is required. Substantive experience dealing with health care regulators and regulatory agencies is required. Compliance Program management experience required. Strong people, project, and change management skills . Demonstrated leadership, ability to drive results and engage senior leaders, and ability to influence cross-organizational stakeholders and decision makers with different operational responsibilities. Proven track record of building consensus, forging coalitions and leveraging professional relationships to achieve strategic objectives and to create an effective “culture of compliance”.
Ref - 17001E5
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