Director Compliance, Geisinger Health Plan

Job Summary

Job Duties

• Responsible for the development, implementation and maintenance of a compliance program for all lines of business. This includes annual audit readiness reviews, strategic initiatives to improve compliance.
• Provides strategic direction to business areas in support of, and in anticipation of, regulatory guidance and sub-regulatory guidance across all lines of business.
• Proactively identifies regulatory trends to support and guide business decisions.  
• Actively leads, records, and assists with activities of the Compliance Committee and its subcommittees and other committees and work groups.
• Ensures appropriate Compliance Committee reporting and oversight for all lines of business.
• In-depth regulatory research as needed.
• Acts as the principle point of contact for interacting and communicating with the CMS-assigned Medicare Plan Account Manager, CMS staff, other regulators as needed.
• Will supervise and oversee routine compliance communications with regulators    on behalf of the Chief Compliance Officer and/or CEO and Associate Chief Legal Officer for all lines of business.
• Manages the development and presentation of annual Compliance Program risk assessment, annual work plan to support Compliance Program objectives, and completion of annual third-party Compliance Program Effectiveness audit.
• Present and communicate the risk assessment and work plan to impacted Health Plan Departments and senior leadership.
• Provide consultative support to business areas across GHP and supports in the development of annual operations work plans to mitigate risk for program activities.
• Interfaces with all applicable departments to coordinate and monitor compliance with applicable regulatory requirements for all lines of business and reports these results to the appropriate administrative departments, Chief Compliance Officer and Compliance Committee.
• Reviews and provides guidance to Compliance staff on regulatory requirements and administrative reporting obligations.
• Coordinates and leads communications with senior leadership to ensure that line of sight is maintained on regulatory and compliance risk areas.
• Leads the development of and provides oversight for the implementation and maintenance of a regulatory compliance education plan, the investigation and remediation process and the auditing and review process which monitors compliance with applicable regulations regarding, but not limited to, sales and marketing, contracts, medical management, complaints and grievances, provider relations, health plan operations, quality improvement, record keeping and documentation.
• Leads specific Compliance Department initiatives and serves as the lead and primary interface with external auditors.
• Actively develops, implements, updates, and oversees a training and education regimen for new employees within the Compliance Department.
• Oversees project management initiatives that include a required compliance process, both within the Compliance Department and when applicable, operational areas.
• Coordinates the maintenance of a formal system to receive and record internal complaints and reports regarding internal practices or actions which do not comply with applicable state and federal regulatory requirements.
• Responsible for building and maintaining high performing compliance team.
• Responsible for individual development of team members.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

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Position Details

Our ideal candidate has:

• Minimum of 10+ years demonstrated strong managed care compliance or regulatory experience.
• 10+ years working in Government Services, Health Plan, Regulatory agencies or other Industry Groups with the ability to leverage people both inside and outside of the organization to support Health Plan compliance and build relationships.
• Sound business judgment and acumen.
• Ability to work independently with limited guidance.

Required:

Certified in Healthcare Compliance (CHC)

Education

Experience

Certification(s) and License(s)

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