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Organization TypePublic Interest
Years of Experience
Date Last Verified
ProfilePHP-Compliance Officer Duties: Responsible for general participation in the ongoing development of compliance and privacy functions within Health System firm. Oversight and responsibility for promoting, monitoring, and auditing internal and external compliance with all laws, regulations, rules, policies and procedures. Coordinate the planning, design, implementation, communication and monitoring of the PHP corporate compliance program. Coordinate the promotion of an awareness and understanding of ethical, moral and legal principles. Promote accurate billing, coding and privacy requirements through auditing and monitoring of related policies and controls. Perform annual risk assessment to determine areas of priority for potential compliance review. Develop an annual compliance and privacy work plan for review and presentation to executive management. Coordinate all external compliance reviews by government, accreditation and regulatory agencies, and monitor compliance efforts throughout the organization. Establish and maintain a positive working relationship with regulatory agencies, and function as the health plan liaison with regulatory agencies and government officials regarding licensing, reporting, customer complaints, administrative site visits, legislative and policy changes. Monitor regulatory filings required and submitted by PHP. Work with Sparrow Health System legal and outside counsel to provide legal support and compliance to PHP. Provide compliance and legal support to PHP Senior Management team. Attend monthly Legislative Committee meetings at MAHP. Report relevant legislative issues to PHP leadership. Maintain and update educational materials for caregivers regarding compliance issues and changes in state or federal requirements related to individual job responsibilities and coordinated with orientation process. Maintain a confidential communication system consistent with SHS compliance program for caregivers to report potential or known compliance departures, including conducting and coordinating any investigations with health system compliance and/or legal counsel, and responding to identified areas of potential violation. Maintain documentation of detected non-compliance and corrective action taken as a result of the non-compliance. Act as the PHP Privacy Officer, overseeing all ongoing activities related to development, implementation, maintenance of and adherence to PHP’s policies and procedures regarding the HIPAA Privacy rules; and assess, implement and monitor all aspects of HIPAA and other federal and state laws. Review and monitor content / accuracy of member information (certificates, handbooks, marketing materials, newsletters, etc.) to ensure compliance with state and federal regulations. Oversee and monitor activities of the fraud and abuse process, including the PHP Billing Integrity Program. Responsible for implementation of programs for detection, prevention and investigation of provider billing errors, abuse and fraud. Provide regular update reports for the Sparrow Health System VP. Audit, Compliance & Privacy, and attend SHS Compliance Management meetings and other meetings.
Qualification and Experience
Qualifications: Bachelor’s degree in accounting, finance or health care administration, / Bachelor's degree in another field with additional education and/or experience in health or legal related field. 5+ years experience in insurance/health care plans/health care benefits experience. Knowledge of state licensing, regulatory and government program requirements and state and federal laws related to health care benefits. Strong written and oral communication skills, interpersonal skills, leadership skills and presentation skills. Ability to prioritize workload and work independently. Strong computer skills, including all Microsoft Office products. Prefer: Law degree/legal experience. Experience in managed care compliance and heath care benefits and ERISA plans. Experience in Fraud and Abuse program development and implementation. Knowledge of standard medical coding practices and procedures.