Supervisor of Program Integrity

Oversees the day-to-day operations of Partnership HealthPlan of California’s (PHC) Program Integrity Unit. Responsible for ensuring the timeliness of investigations related to potential or actual HIPAA and fraud, waste, and abuse. Supports training, provides direction to the Regulatory Affairs and Compliance (RAC) staff, and serves as an effective liaison for the organization and its internal and external community.

Responsibilities

With RAC leadership, supports the management and goal setting for program integrityoperations

Supervises Regulatory Affairs Specialists and ensures staff follow procedures, policiesand protocols. Defines scope of work, deliverables and timeframes directly with seniorstaff

Researches complex HIPAA and/or fraud cases to ensure accurate and timely responseutilizing all applicable State and Federal regulations, available data and documentation,and facts of the case. Facilities case conferences with RAC leadership as needed

Supports PHC’s multi-faceted approach to detect and protect against fraud activity

Responsible for the completeness and accuracy of the tracking systems and records of allreports and investigations related to potential or actual HIPAA and/or fraud

Participates and represents PHC in meetings and calls with regulators and associationsand summarizes key points and impact to PHC programs

Provides HIPAA/FWA training and education to PHC operational departments to promoteawareness of and adherence with program integrity requirements

Maintains work plans, dashboards, and other tools intended to provide transparency andaccurate reporting of program integrity activities and trends

Responsible for monitoring industry trends and making recommendations for PHC’sprogram to proactively mitigate HIPAA and/or fraud risks and develops and supportsimplementation of interventions

Secondary Duties and Responsibilities

Participates in special projects and assignments, as needed.

Qualifications

Education and Experience

Bachelor’s Degree in Liberal Arts, Business Administration, HealthCare Administration, Political Science, or related field with two - three(2-3) years’ experience in the health care compliance field, withknowledge of the Knox-Keene and Medi-Cal regulations; or anequivalent combination of education and experience (4-5 yearsminimum health care experience).

Special Skills, Licenses and Certifications

Certification in Healthcare Compliance (CHC) preferred or obtainedwithin 12 months of hire. Highly proficient in applicable businesssoftware applications including PC usage, Microsoft Word, PowerPointand Excel. Knowledge of Policy development. State and federallegislative processes. Medi-Cal programs. Research and programplanning methodology. Project Management. Valid California driver’slicense and proof of current automobile insurance compliant with PHCpolicy are required to operate a vehicle and travel for companybusiness.

Performance Based Competencies

Excellent oral and written communication skills. Excellentorganizational skills with ability to prioritize assignments. Performpolicy development and implementation in the areas of Medi-Cal, otherinsurance programs, long-term care, mental health, and other healthrelated programs. Demonstrated analytical skills. Ability tocommunicate effectively, both verbally and in writing. Perform ProjectManagement activities.

Work Environment And Physical Demands

Ability to use computer keyboard and other business machines. Morethan 50% of work time is spent at a computer monitor. When required,ability to move, carry, or lift objects of varying sizes, weighing up to 35pounds.

All HealthPlan employees are expected to:

Provide the highest possible level of service to clients;

Promote teamwork and cooperative effort among employees;

Maintain safe practices; and

Abide by the HealthPlan’s policies and procedures as they may from time to time be updated.

HIRING RANGE:

$103,059.95 - $133,977.94

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

Regular Full-Time