The role of the Operations Compliance Program Manager (PM), through the use of general knowledge of Plan benefits and regulatory requirements, is to provide support to Operations division including but not limited to:
* In conjunction with the Business area, is responsible for supporting the development and implementation of these policies and to ensure compliance with all regulatory requirements
* Provides support to the work done in all lines of business
* The PM represents the division and the Plan when working with review agencies (OPP), accreditation agencies (NCQA and CMS), providers, high profile employer groups (GIC and USFHP).
* Develop new programs as well as management of ongoing complex programs.
The PM needs to demonstrate strong professional judgment and apply risk management in highly escalated situations. They need to possess process re-engineering skills as well as to be able to understand root cause analyses.
KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS* (in order of importance)
Compliance Oversight for Operations
* Prepare Operations departments for the CMS's site visit
* Oversee implementation of departmental corrective action plans to ensure accurate and timely implementation/execution
* Provide/supervise technical consultation/support to staff and other departments in response to regulatory compliance and policy issues
* Oversee design, content and conduct of support and compliance training activities for the Operations department with assistance from Corporate Compliance and/or Operation Quality Assurance and Learning and Development
* Manage development, implementation, and monitoring of Compliance and Risk Management activities
* Complete yearly readiness checklist with support from the Operational areas
* Undertake investigations of regulatory and compliance inquiries prepare reports and monitor remediation.
* Responsible for the implementation and oversight of applicable regulatory changes; responsible to review and work with the department manager and supervisors to update current processes to remain in compliance with applicable standards and assist them in understanding how these standards impact their work and overall company and regulatory compliance.
* Manage, document and maintain a coordinated regulatory compliance program that meets the expectations of the TMP and Corporate Compliance program by monitoring federal and state guidance, regulations and other sources of requirements, investigating regulatory and compliance inquiries, preparing reports and monitoring remediation
Manages major compliance programs with significant cross-functional interface with significant complexity and risk. Responsibilities include development of new programs as well as management of ongoing programs.
* Develop and implement programs, policies, procedures and practices designed to ensure compliance with the requirements of State and Federal health care programs, and
* Identify compliance risks and work to develop and implement mitigation strategies to address identified issues to ensure compliance with these regulations.
* Represent the departments on regulatory and compliance related work groups and Committees as appropriate.
* Identify training needs and develops appropriate resources
* Support department in the development of actionable compliance oversight plans
Liaison between Operations with the Compliance Department
* Work collaboratively with the Compliance Program, the Corporate Compliance and Privacy Program, and other THP departments on Medicare compliance matters as necessary or identified
* Serve as the liaison between Compliance, Legal and the respective business owner(s) for issues pertaining to regulatory compliance, and "interpretation", dissemination and implementation of regulatory
* Coordinate materials and reports and provide updates and reports to the appropriate and relevant TMP compliance committee
Liaison with multiple external constituencies including but not limited to: review agencies (OPP, CMS, EOHHS, DOI), accreditation agencies (NCQA), providers, or high profile employer groups.
* Disseminate knowledge of THP policies and processes as it is related to the external constituent
* Represent the department as the SME for regulatory site visits
* Act as SME for regulatory submissions and in preparing for site visits
* Support Business owners to assess, implement, and respond to Regulatory Agency requests for process review and update.
Other duties as assigned