About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and and SCFHP DualConnect (HMO D-SNP) health care plans.

About the role:

The Compliance Officer oversees the compliance program and staff to ensure the Plan is compliant with applicable laws and regulations (including those related to Medicare, Medi-Cal, and Knox-Keene Act requirements), identifies and manages areas of risk, and maintains positive relationships with regulators and policymakers. This individual has direct access to the Chief Executive Officer and to the Santa Clara County Health Authority (SCCHA) Governing Board, for the purpose of advising and making recommendations about regulatory compliance issues. The scope of responsibilities includes serving as Privacy Officer and coordinating security matters with the Chief Information Officer, as well as coordinating compliance activities with Santa Clara Family Health Plan (SCFHP) operational areas.

Day to Day:

• Provide strategic leadership to Compliance operations, including the development and distribution of written standards of conduct and policies and procedures that promote the organization’s commitment to, and culture of, compliance.
• Implement, document, and maintain a coordinated regulatory compliance program that meets regulatory expectations across all lines of business.
• Lead development and implementation of compliance training and education programs for all key stakeholders, establishing compliance expectations of Board members, staff, consultants, and First Tier, Downstream, and Related Entities (FDRs) to meet all applicable statutory and regulatory requirements.
• Determine the appropriate structure and staffing of the compliance function, and lead the compliance team by continuously engaging and developing compliance leaders and specialists, who work collaboratively with business units on cross-functional activities.
• Provide oversight and monitoring of operations through maintenance of a compliance dashboard reflecting organizational performance on Medi-Cal and Medicare regulatory requirements.
• Ensure that policies, procedures, and practices are designed to promote compliance with the requirements set forth by regulators, including oversight of all FDRs, and screening of all required stakeholders against appropriate regulatory databases.
• Develop a robust audit program to monitor internal departments and external delegated entities to ensure compliance with applicable regulations, policies, and OIG elements of an effective compliance program.
• Develop a robust Fraud Waste and Abuse (FWA) program, and encourage staff to report noncompliance, FWA, and other misconduct without fear of retaliation and with an opportunity for anonymity.
• Provide oversight and maintenance of the compliance hotline, and processes to receive and resolve complaints and concerns, including investigations of alleged regulatory and policy violations.
• Develop positive and productive relationships with regulators to foster partnership on regulatory issues and promote the Plan’s position as a respected stakeholder. Ensure timely and accurate regulatory reporting, responses, and corrective actions.
• Coordinate external regulatory audits including those by CMS, the California Department of Health Care Services (DHCS), and the California Department of Managed Health Care (DMHC), as well as any required remediation and/or corrective action plans.
• Advise the CEO on anticipated regulatory changes and potential impact to benefit programs and the organizational profile.
• Provide compliance reports at least quarterly to the Governing Board on the status of the compliance program, the identification and resolution of potential or actual instances of noncompliance, and external regulatory audits.

About You:

• Bachelor's degree in Healthcare Administration, Public Health, Business, or related field.
• Minimum of five years of related experience leading a managed care compliance program that meets federal and state requirements.
• Minimum of five years of experience in management positions demonstrating increased levels of accountability.
• Previous Medicare, Medicaid, and HIPAA regulatory experience in a managed care entity.
• Previous experience working with federal and state regulators on compliance-related issues.
• Previous experience supporting a compliance committee structure and working with a governing board.
• Leadership skills, ability to coach and mentor.
• Public speaking and presentation skills.

Please review the full job description on our Career’s page: https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=2841

Job Type: Full-time

Pay: $189,616.00 - $303,385.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• San Jose, CA 95119: Reliably commute or planning to relocate before starting work (Preferred)

Application Question(s):

• Do you have previous Medicare, Medicaid, and HIPAA regulatory experience in a managed care entity?
• Do you have previous experience working with federal and state regulators on compliance-related issues?
• Do you have five years of experience in management positions demonstrating increased levels of accountability?
• Do you have five years of related experience leading a managed care compliance program that meets federal and state requirements?

Education:

• Bachelor's (Preferred)

Work Location: One location

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