Compliance Specialist

SUMMARY:

Under leadership of the Director of Risk & Compliance the Compliance Specialist monitors executes and enforces Gracelight Community Health Compliance Program. The Compliance Specialist works directly with management and staff and is the primary contact for the delivery of compliance level engagements and training on both department specific and organizationwide compliance initiatives. Additionally assist the Credentialing Department in coordinating monitoring and maintaining the credentialing recredentialing and privileging process.

The Compliance Specialist assists with companywide integrated risk assessments; thirdparty vendor management audit management investigates possible compliance violations and grievances incident management and policy and procedure management. The Compliance Specialist monitors and reports on corrective action plans and provides staff training and education.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:

Compliance

• Supports and implements the organizations vision mission and values.

• Determines priorities and method of completing daily workload to ensure that all responsibilities are carried out in a timely manner.

• Fosters and promotes a culture of service excellence and accountability.

• Performs all job functions in a professional and courteous manner. Conduct is customer service oriented professional and objective. This includes answering all phone calls and emails timely and providing excellent customer service to internal and external customers.

• Performs job duties independently and exercises good judgment.

• Manages the organizations thirdparty vendor relations and contract administration to include review of contract documents setup of applicable software system role assignment security settings and overseeing the review/approval process.

• Manages the organizations document management systems to ensure corporate records contracts agreements and other records are maintained in compliance with filing access destruction and retention policies. Manages and coordinates document/media clean up days.

• Promotes a heightened awareness and understanding of standards of conduct and ethics; new and existing compliance issues; related policies and procedures and use of reporting systems including the compliance hotline.

• Oversees maintains manages tracks and assists in the preparation and revision of organizational policies and procedures.

• Coordinates compliance review and monitoring activities including periodic reviews of departments.
• Assists with external audits and inspections conducted by contracted health plans and federal state and county entities. Assists Director of Operations and Health Center Managers to prepare for audits and respond to resulting Corrective Action Plans (CAPs); reports and tracks status of CAPS.

• Promotes develops and conducts compliance training and education for all staff. Ensures that employees independent contractors and vendors are trained in the requirements of the compliance program. Monitors completion of compliance related trainings in organizations learning management systems and ensures completion.

• Maintains the companys incident management system and is responsible for ensuring that departments are reporting investigating correcting and closing incidents in a timely manner.

• Collaborates with other functional departments and Director of Risk & Compliance to resolve difficult compliance issues.

• Develops systems for tracking outcomes and ensuring that all governmental requirements are met.

• Maintains absolute confidentiality in all matters related to audits investigations incidents or any potentially confidential matter.

• Maintains current knowledge of relevant compliance regulations trends and practices.

• Oversees grievance and incident management across all related departments and collaborates with other functional departments to ensure that all grievances and incidences are investigated and resolved in a timely and professional manner while ensuring the privacy and confidentiality of patients staff and providers. Reports patientrelated incidents and grievances to the quality committee.

• Uses discretion while performing duties and responsibilities while handling sensitive or confidential information and exercises good judgement.

• Complies with organizational policies and procedures.

• Composes neat legible complete and accurate documentation in a timely manner.

• Performs other duties as assigned.
• Must be willing and able to work at all locations as needed to meet patient care needs.
• Must be willing and able to work all business hours including evenings and weekends.
• Credentialing
• Participates in the development and implementation of process improvements for the systemwide credentialing process; prepares reports as required by regulatory and accrediting agencies policies and standards.
• Conducts primary source verification collects and validates documents to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards and organizational criteria.
• Enters updates and maintains data from provider applications into credentialing database focusing on accuracy and interpreting or adapting data to conform to defined data field uses and in accordance with internal policies and procedures. Files and maintains confidential credentialing and privileging files.
• Prepares issues electronically tracks and followsup on appropriate verifications for efficient high volume processing of individual applications in accordance with applicable credentialing standards established procedural guidelines and strict timelines.
• Followsup on appointment letters processes requests for additional privileges and explains the reasons/s for the condition/limitation/deferment. Maintains forms and templates and credentialed staff information.
• Drives to various clinic and administrative locations to collect signatures deliver documents mail or ship and/or collect forms as needed.
• Enters updates and maintains data from provider applications into credentialing database focusing on accuracy and interpreting or adapting data to conform to defined data field uses and in accordance with internal policies and procedures. Files and maintains confidential credentialing and privileging files.

JOB KNOWLEDGE AND SKILLS:

• Demonstrates required knowledge skills and education for job functions.
• Demonstrates exceptional leadership skills and a high level of emotional intelligence.
• Demonstrates broad knowledge of and competency in compliance functions; demonstrates familiarity with healthcare laws regulations and standards to include but not limited to HIPAA Privacy and Security HRSAs 19 Program requirements Federal Tort & Claims Act 340 B Drug SB137 Generally Accepted Accounting Principles (GAAP). Knowledge of audit and investigative tools practices and methodologies; insurance plan requirements and regulations.
• Demonstrates understanding of business and general computer controls in the following areas: clinical accounting billing HR payroll credentialing risk management governance / risk and other relevant applications/systems.

QUALIFICATIONS:

To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge skills and ability required. The physical demands and work environment characteristics described are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION/EXPERIENCE:

1. Bachelors Degree required; training in healthcare compliance preferred.
2. Minimum of two 2 years experience in a healthcare/health center/hospital setting desired.
3. Familiarity with contract administration and regulations desired.

LANGUAGE SKILLS:

Ability to read and interpret documents such as policies and procedures financial statements benefits information benefit surveys board minutes routine mail simple contracts and instruction manuals. Ability to compose routine reports and correspondence and speak effectively with employees visitors and management. Possession of excellent communication skills both oral and written. Ability to foster a cooperative work environment.

MATHEMATICAL SKILLS:

Ability to calculate figures and amounts such as discounts interest commissions proportions percentages and apply concepts of basic algebra and geometry.

REASONING ABILITY:

Ability to exercise common sense in carrying out instructions furnished in written oral or diagram form and in other daily situations that arise. Ability to deal with problems involving several concrete variables in standardized situations. Ability to make decisions and execute timely to produce a positive outcome.

OTHER SKILLS AND ABILITIES:

1. Demonstrates ability and flexibility to work in other areas of the organization as needed.
2. Demonstrates required knowledge skills education for job functions.
3. Able to organize and prioritize work with minimal supervision.
4. Adjusts to changes in tasks and priorities. Seeks accepts and acts on feedback.
5. Maintains and promotes a safe work environment.
6. Demonstrates excellent communication skills both oral and written.
7. Demonstrates proficiency in computer applications such as Microsoft Excel Power Point Word Outlook and other software facilitating workflows for incident reporting audits contract administration and policies and procedures.
8. Displays positive outlook on the job and promotes professional behavior always.
9. Interacts appropriately with diverse populations and different community groups. Sensitive to multicultural issues.
10. Must have own automobile Valid California Driver License and active automobile insurance.

PHYSICAL DEMANDS:

While performing the duties of this job the employee is regularly required to use hands to finger handle or feel and reach with hands and arms. The employee frequently is required to stand walk and sit. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 30 pounds. Specific vision abilities required by the job include close vision color vision and ability to adjust focus.

WORK ENVIRONMENT:

The noise level in the work environment is often low. However there are many times when there is a high ambient background noise of phones and multiple conversations. Employee must be able to screen out background noise to concentrate on work at hand.