VP Compliance Officer

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VP Compliance Officer
DUTIES: Develops initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct. Manages day-to-day operation of the Compliance Program. Periodically reviews and updates the Code of Conduct and the Conflict of Interest policy to ensure continuing currency and relevance in providing guidance to Board and Committee members, management and employees. Assists the business units in developing strategies for the organization to reconcile all capitation payments, premium revenue, internal and external claims payments, clinical/utilization data and member eligibility. Ensures the respective units have processes in place to internally monitor and report payment inaccuracies. Advises and collaborates on the development and revision of policies and procedures for the general operation of the business units and related activities to ensure accurate financial performance by each business unit/department and the payors contracted with the organization. Develops and oversees the implementation, development, and maintenance of operational controls, and programs for reconciliation and integrity of the reporting of SWHR data. Acts as an independent review and evaluation body to ensure that compliance issues / concerns within the organization are being appropriately evaluated, investigated and resolved. Collaborates with other departments (e.g. HR, Internal Audit, Physician Network, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the Office of the Chief Legal Officer of SWHR as needed to resolve legal compliance issues. Responds to alleged violations of rules, regulations, policies, procedures, and the Code of Conduct by evaluating or recommending the initiation of investigative procedures. Develops and oversees a system for uniform handling of such violations. Monitors, and as necessary coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends. Identifies potential areas of compliance vulnerability and risk; develops / implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in the future. Provides reports on a regular basis, and as directed or requested, to keep the SWHR Audit and Compliance Committee and senior management informed of the operation and progress of compliance efforts. Monitors key performance and risk indicators/metrics to assist with the early identification of risk trends across various operational units. Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline; (b) heightened awareness of the Code of Conduct and the Conflict of Interest policy, and (c) understanding of new and existing compliance issues and related policies and procedures. Works with Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees as well as ongoing training for all employees. Participates and coordinates the external compliance audits from entities providing oversight including but not limited to, contracted payors, State Departments of Insurance (e.g. TDI), and CMS.

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