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Organization TypePublic Interest
Years of Experience
Date Last Verified
Manager Commercial Compliance Duties: Responsible for providing effective leadership for Health Plan in the areas of: federal and State legislative analysis and implementation; regulatory affairs, government relations, compliance, privacy, security, fraud/waste/abuse; government contracts, including CalPERS and Covered California; and delegation oversight. Chairs the Planâ€™s Compliance Committee. Develops analyses and recommendations for programs and goals. Implements project/action plans to ensure Health Planâ€™s continued compliance with all applicable legislative, regulatory, contractual and accreditation requirements in a manner that is consistent with the Planâ€™s vision, mission and goals. Develops and maintains subject matter expertise on contractual, legislative and regulatory issues affecting health plans in California. Establishes communication plans to ensure that Plan staff, leaders and delegated entities understand and comply with contractual, legislative and regulatory requirements. Responsible for ensuring the implementation of such contract requirements, laws and regulations. Directs follow-up assessment of implementations and ongoing activities. Develops organizational policies and procedures in support of compliance. Interacts effectively with various internal and external departments to provide guidance, information and assistance. Efficiently and effectively documents information and activities for use in communication, education and monitoring. Presents reports on compliance activities to the President/Chief Executive Officer and Board of Directors. Promotes the satisfaction, development and productivity of the Regulatory Affairs staff. Participates as part of, and in support of, a management team that works collaboratively to ensure the success of Planâ€™s goals, objectives, and strategic initiatives.
Qualification and Experience
Qualifications: Undergraduate degree in business, law or health care. 5 years' experience in position requiring high levels of cooperation, collaboration, and management of staff. Experience in a leadership role, ideally leading and implementing a comprehensive compliance program. Experience conducting research, thorough analysis, and interpretation of findings. Knowledge of state and federal regulations including California Code of Regulations, especially Title 28, and the Knox-Keene Act. Knowledge of health plan operations. Familiarity with implementation of applicable federal laws including but not limited to ERISA, COBRA, HIPAA, IRS, Public Health Services. Experience with and knowledge of National Association of Insurance Commissioners (NAIC) model rules and other standards. Knowledge of accreditation standards related to delegation oversight, privacy, security and other applicable areas. Ability to analyze and interpret data, and prepare concise, accurate reports. Ability to make strategic and tactical recommendations. Preferred: Masters/JD Degree. High level of integrity; ability to exercise sound judgment and maintain confidentiality. Exceptional diplomacy skills to effectively resolve issues under sometimes stressful circumstances. Readily adaptable to the changing needs of the business; able to manage multiple priorities; tolerance for ambiguity. Excellent organizational and time management skills. Excellent business acumen and writing skills. Experience with electronic mail, word processing, spreadsheets, database programs and Internet research. Effective interpersonal skills; excellent oral and written communication skills. Professional presentation skills including public speaking. Able to represent Health Plan effectively in dealings with peers and executives (internal and external), legislators, regulators, consultants, vendors and other outside parties who contribute to the success of Health Plan.
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