Compliance Specialist - Delegation Oversight
PacificSource

Job Info

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Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Position Overview: The Delegation Oversight Specialist will be primarily responsible for executing various aspects of the Delegation Oversight program. Primary responsibilities will include executing oversight strategies of First Tier, Downstream, and Related Entities (FDRs) and Subcontractors to ensure these third parties perform in accordance with contractual provisions as well as all state and federal regulatory requirements.

Essential Responsibilities:

• In collaboration with business relationship managers (BRMs), effectively oversee the performance of FDRs and Subcontractors that perform a delegated functions on behalf of PacificSource.
  
• Execute the annual delegation oversight work plan.
  
• Plan and execute annual FDR and Subcontractor annual performance audits.
  
• Plan and execute pre-delegation assessments of all newly contracting FDRs and Subcontractors in accordance with CMS and OHA requirements.
  
• Initiate and execute investigations into potential non-compliance by an FDR and/or Subcontractor.
  
• Initiate and coordinate corrective action plans for non-compliance identified within FDRs and Subcontractors
  
• Prepare and submit FDR and Subcontractor regulatory reports to CMS and OHA.
  
• Remain current in federal/state laws and regulations, industry standards and best practices around compliance and delegation oversight
  
• Coordinate delegation oversight by maintaining collaborative partnerships with key departments.
  
• Participate in process improvement initiatives and work with other departments to improve interdepartmental delegation oversight processes.
  

Supporting Responsibilities:

• Participate in compliance initiatives as needed.
  
• Perform day to day tasks of the compliance department as needed.
  
• Meet department and company performance and attendance expectations.
  
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  
• Perform other duties as assigned.
  

SUCCESS PROFILE

Work Experience: Minimum 2 years related experience in healthcare/health insurance compliance required. Minimum 2 years related experience with Medicare and/or Medicaid programs required. Minimum 2 years specific experience with oversight of third parties (delegation oversight) required.

Education, Certificates, Licenses: Bachelor's degree in Business, Health Care Administration, or a related field strongly preferred or high school degree and equivalent work experience.

Knowledge: Ability to gain a thorough understanding of PacificSource delegation oversight program and compliance initiatives. Ability to apply complex analysis, evaluation, and problem solving skills to assess a third party's contractual performance. Respond timely to regulatory inquiries. Maintain sufficient reference materials to adequately research compliance issues. Ability to organize large projects that involve working with multi-functional teams under strict deadlines. Ability to communicate effectively with all levels of the organization both verbally and in writing. Working knowledge of medical terminology. Ability to read and understand delegation contracts and health benefits language. Ability to work under time pressures, and to deal with emotional situations.

Competencies

• Adaptability
  
• Building Customer Loyalty
  
• Building Strategic Work Relationships
  
• Building Trust
  
• Continuous Improvement
  
• Contributing to Team Success
  
• Planning and Organizing
  
• Work Standards
  

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

This job has expired.