Compliance and Privacy Officer

Position Overview

Location: Smithfield, RI (On-site)

The Compliance and Privacy Officer has primary responsibility for Neighborhood Health Plan of Rhode Island's compliance with federal (Medicare Part C and Part D), state and local laws, Medicaid, rules and regulations. The position manages assigned compliance staff; chairs the Compliance Committees and is responsible for implementing, coordinating, and providing day-to-day management and oversight of Neighborhood's Compliance, Privacy and Fraud, Waste and Abuse (FWA) Programs.

Duties and Responsibilities -

Responsibilities include, but are not limited to, the following:

• Develops, implements, maintains and coordinates Neighborhood's Compliance Program and Standards of Business, ensuring all necessary elements are addressed

• Leads Neighborhood's Compliance Committee.
• As required and no less than quarterly, provides necessary Compliance reports to the Board of Directors, CEO, COO, CMO, CFO and Compliance Committee.
• Point of contact for external relationship with CMS for contractual and regulatory compliance reporting.

• Ensures the maintenance of necessary compliance reporting mechanisms and documentation to meet federal and state contractual and regulatory requirements including:

• oversight of regulatory reporting, including monitoring to ensure timeliness and review of trends or other compliance key performance indicators
  
  
  
  • vendor/first tier, downstream, related entity (FDR) compliance/reporting including pre-delegation reviews
  • non-compliance with specific elements of Neighborhood's Compliance Program, Standards of Business Conduct or FWA received from any source;
  • any identified instances of conflicts of interest for all staff members, board members, and other applicable members of Neighborhood's workforce;
  • on-going and / or completed compliance-related investigations;
  • in coordination with the specific department Director and, as required, the Director of HR oversees and assists managers to create corrective action plans to identified compliance issues or concerns as required, monitors and ensures corrective action plans are implemented.
  • Conduct validation reviews and risk assessments to evaluate against Medicare Part C Part D, Medicaid contract requirements or as otherwise as needed. Develop an annual compliance work plan informed by risk, issue identification and other sources as available.
  
  
  
  

• Conducts and / or supervises the execution of Compliance Program related audits and investigations.

• Monitors government announcements, rules, regulations and guidance; and in collaboration / coordination with designated Product / Program Managers and department Directors ensures that Neighborhood departments and staff members are kept informed of and implement required regulatory / procedural change.
• Serves as a subject matter expert for management and staff on the conditions and terms of CMS contracts along with other laws and regulations pertaining to Neighborhood's other lines of business.
• Ensures Compliance Department policies are reviewed and updated on a regular basis, reflecting applicable State and Federal regulatory changes.
• Oversees assigned staff members. Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions.

• Oversees the identification, implementation and maintenance of the Privacy Program in compliance with the Health Insurance Portability and Accountability Act (HIPAA), as well as other state and federal laws inclusive of:
  
  
  
  • Establishing a process for receiving, responding and resolving reported incidents.
  • Establishes and maintains a mechanism to track access to protected health information.
  • Collaborates with Enterprise Risk and Information Security, Information Systems (IS) and other stakeholders to identify and manage risks.
  • Oversees the monitoring of the company's compliance with its privacy obligations. Responsible for implementing industry standard incident response procedures and responds to potential breaches of the company's privacy
  
  
  
  
• In coordination with the Director of Human Resources collaboratively develops and ensures implementation of methods and programs that encourage all staff members to report, without fear of retaliation, noncompliance with:

• Neighborhood's Compliance Program,
• Neighborhood's Standards of Business Conduct;
• applicable state and federal regulations, guidelines and laws; and
• suspected incidents of FWA.

• In coordination with the Director of HR, collaboratively ensures that the HHS OIG exclusion lists and GSA debarment lists are checked with respect to all employees, officers, directors, vendors/subcontractors and other appropriate members of Neighborhood's workforce within required time frames.

• In coordination / collaboration with the Director of HR acts as a subject matter expert related to any education and training associated with and required by state and federal regulations, Neighborhood's Compliance Program and Standards of Business Conduct, compliance policies and procedures, and all applicable statutory and regulatory requirements for all staff members, board members, and other applicable members of Neighborhood's workforce.
• Interacts with Neighborhood's operational units and is involved in and aware of the daily business activity of the organization.
• Utilize available compliance system and tools to support an effective compliance program, while also documenting key work flows, policies and procedures of the Compliance department.
• Develop or participate in QI projects directly related to Compliance or other business areas.
• Other duties as assigned by his / her supervisor.
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Core Company-Wide Competencies:

• Communicate Effectively
• Respect Others & Value Diversity
• Analyze Issues & Solve Problems
• Drive for Customer Success
• Manage Performance, Productivity & Results
• Develop Flexibility & Achieve Change

Job Specific Competencies:

• Collaborate & Foster Teamwork
• Attend to Detail & Improve Quality
• Plan & Organize
• Exercise Sound Judgement & Decision Making

FDR Oversight:

• Senior Leadership Level:

Assures effective oversight and monitoring of the performance of all applicable First Tier, Downstream and Related Entities (FDR) so that the services being provided are consistent with all contractual and legal requirements as well as company policies and procedures

Travel Expectations:

• Minimal travel required

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

Qualifications

Required:

• Bachelor's degree
• 5 to 8 years of experience in regulatory compliance
• Direct experience with compliance as related to Medicare/Medicaid managed care compliance
• Detailed knowledge of CMS regulations
• Demonstrated ability to work across numerous operational areas
• Demonstrated strong presentation skills
• Demonstrated strong organizational and time-management skills

Experience in health plan operations and managed care

Preferred:

• Master's degree
• Regulatory compliance experience with healthcare law
• Health Care Compliance Association (HCCA) / Society for Corporate Compliance and Ethics (SCCE) certification. (e.g. CHC and/or CHPC)

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.