Compliance Investigator II

Overview

The Regulatory Affairs Specialist II has demonstrated competencies in supporting the plan-wide regulatory affairs and compliance program, including activities related to HIPAA and Fraud, Waste, and Abuse (FWA). Under supervision and direction of the Regulatory Affairs Manager, monitors daily Regulatory Affair unit’s operations to ensure the timeliness of deliverables and all case management performance metrics are met, performs internal auditing of all privacy and FWA cases to ensure they meet DHCS requirements and Partnership professional standards. Also provides support to the Regulatory Affairs Specialist (RAS), directs complex regulatory inquiries and responses to regulatory agencies.

Responsibilities

• Proficiently performs all duties of the Regulatory Specialist, independently.
• Operates independently, exercising judgement, and providing support and guidance to Regulatory Affairs and Compliance (RAC) staff
• Encourages continuous awareness and education of unit staff, which may include development and maintenance of training materials
• Creates and monitors daily operational reports to ensure the timely submission of privacy and FWA cases to DHCS
• Manages the intake and ongoing maintenance of referral/inquiry platform
• Ability to assess, facilitate, and see to completion, referrals and inquiries, of varying complexity and scope, submitted to RAC
• Monitors unit trackers to ensure the timeliness of deliverablesare met, making recommendation for improvements in tracking and/or work flows as necessary
• Ability to direct unit work, which may include leading unit meetings/discussions and assessment of work outcomes
• Competent in assessing and analyzing unit work consistent with established criteria and providing education/training to unit staff as needed
• Maintains awareness and understanding of regulatory requirements that govern unit responsibilities
• Makes strategic recommendation(s) to improve the accuracy, quality, and/or reporting of case investigations based on audit observations in order to enhance HIPAA and FWA case management performance
• Leads or participates in Regulatory Affairs unit projects and has the capacity to represent unit in cross-departmental projects
• Assists Regulatory Affairs Manager with developing and maintaining compliance training program including but not limited to:
  • Updating new hire compliance trainings and annual training materials
  • Conducting targeted department trainings
  • Acts as a trainer for the Regulatory Affairs unit
  • Backup trainer for new hire trainings or other department trainings
• Works with departments on resolving complex regulatory required submissions
• Assists Regulatory Affairs Manager with duties related to chairing the PTAS and FWA Subcommittees

Secondary Duties and Responsibilities

• Supports regulatory submission process including awareness of deliverables, ad hoc and routine, and completeness and timeliness of submissions
• Assists Regulatory Affairs and Compliance unit with the administrative functions to support unit meetings, workgroups, projects and external audits
• Other duties as assigned

Qualifications

Education and Experience

Bachelor’s degree in relevant field preferred or equivalent combination of education and experience; minimum of two (2) years’ experience as a Regulatory Affairs Specialist or relevant experience in managed care with knowledge of the Medi-Cal, and NCQA requirements, and preferably Medicare and Knox Keene. Experience with the investigation and reporting of HIPAA and FWA related incidents.

Special Skills, Licenses and Certifications

Highly proficient in applicable business software applications including PC usage, Microsoft Word, PowerPoint, Excel, Project, typing speed of 30 wpm. Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business

Performance Based Competencies

Excellent oral and written communication skills. Excellent organizational skills with ability to prioritize assignments, maintain effective filing systems, and meet deadlines. Ability to work under minimal supervision and exercise independent judgment. Diplomacy and tact in handling sensitive information regarding personnel affairs as required. Ability to interact with executives and vendors effectively, handling all assignments with efficiency. Must be able to handle multiple tasks and meet deadlines. Excellent judgment.

Work Environment And Physical Demands

Ability to use a computer keyboard and other business machines. More than 50% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying sizes, weighing up to 35 pounds.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.