The Compliance Delegation Specialist is a member of the Compliance Department. Under the direction of the Supervisor and Manager of Compliance Delegation and in support of the Compliance Officer, this position will assist in the coordination and implementation of Compliance Delegation Programs responsibilities and delegated oversight activities with contracted health plans, entities, and vendors. Assist in monitoring business activities for compliance when regulations change, support departments, and company strategies to ensure compliance with federal, state, and contractual healthcare requirements. Assist in audit preparation and developing reports/tools to monitor and track the implementation and completion of corrective measures. Supports the compliance team on general standards of conduct, FDR, FWA, OIG, HIPAA related matters. Knowledge of Medicaid/Medi Cal, Medicare, and regulations applicable to health plans , medical groups , and IPA’s required.
In addition, the Compliance Delegation Specialist is responsible for establishing and maintaining collaborative, courteous, and professional relationships with health plan representatives as well as interdepartmentally within Pri Med/Hill Physicians. Cooperates with management, collaborates with cross-functional teams, and performs other duties as assigned. The below responsibilities will be carried out and managed under the guidance and supervision of the Supervisor / Manager of Compliance Delegation.
Job Responsibilities

• Serve as Pri Med point of contact for health plan and third parties to receive, manage, track, and coordinate health plan and third- party audit process, requests for information, and correspondence between Health Plans, third parties, and Pri Med.
• Perform tasks and inquiries for audits related to utilization management, claims, credentials, and other audit areas to support business needs.
• Coordinate and prepare audit tasks, including assessing that the request meets the audit scope and delegation/contractual agreements, preparing documents for the audits, reviewing that all responses are fact-based, appropriate, and addressing the request. Identify requests that are inappropriate or redundant and escalate to the Supervisor / Manager.
• Ensure that all deliverables are submitted in a timely manner; tracked and documents are appropriately managed. Coordinate and ensure remediation and the response of any non-compliant findings. Supporting evidence is appropriate and delivered to the requester timely.
• Review of new regulations and regulation updates to determine coordination with the impacted operational departments. Provide an overview and ensure operations teams are familiar with the regulation and understand their respective obligations by required deadlines. Ensure policies and procedures, or other supporting documents are created for the implementation of the new regulation. Deliver supporting evidence demonstrating implementation to health plan partners or third parties when requested.
• Prepare for and manage the response to health plan audits, including but not limited to audit preparation, running of reports, gathering, and preparing documentation and policies, meeting or speaking with auditors, facilitating the audit process, and conducting exit interviews and follow-up.
• Analyze and interpret health plan audits results and distribute them to operational departments. Track and trend all health plan audit findings, collaborate with operational departments to implement strategies for future risk mitigation and improvement as it relates to those findings. (i.e. in the following areas: claims, pre-delegation audits, credentialing, provider access and availability survey results, and utilization management. Collaboratively work with any impacted departments.
• Work with relevant operational departments to develop and implement health plan audit readiness strategies.
• Present audit results (findings/corrective action plans (CAPs) to operational departments.
• Publish audit results internally as a resource for interdepartmental process improvement and/or best practice examples.
• Actively participate in the development of the Compliance team’s risk assessment, work plan, and ongoing monitoring of policies, procedures, processes, and legal/regulatory requirements as they relate to health plan requirements.
• Proactively reach out to health plans under the direction of the Supervisor / Manager of Compliance Delegation with questions, clarification, or requests as needed.
• Maintain an up-to-date awareness through education and research of health plan requirements as they relate to Pri Med/Hill Physicians.
• Provide educational materials and general/targeted training to the organization on health plan requirements, readiness strategies, trends, policies & procedures, etc.
• Prepare presentations to support and actively participate in the Compliance Delegation Committee.
• Keep Compliance Teams, Supervisor and the Manager of Compliance Delegation always updated.
• Assist with other functions as needed.
• Availability before and after business hours to support compliance department functions, and business needs.
• Conduct follow-up and provide timely responses to Health Plan requests, including but not limited to requests related to and involving audits, Pri Med/Hill Physicians policies and procedures, reports or processes.
• Develop and implement Corrective Action Plans (CAPs) initiated by Health Plans.
• Attend calls, meetings, and other education sessions, as well as research and keep up to date on Health Plan requirements as they relate to Pri Med/Hill Physicians.
• Other duties as assigned.

Required Experience

• 5 plus years of experience with managed healthcare and health plan audit compliance
• Knowledge of NCQA, CMS, DMHC, DHCS, California Health and Safety Codes
• Knowledge of and direct experience with federal and state fraud, waste and abuse (FWA) laws
• Previous managed care compliance experience.
• Familiar with Medicare and Medicaid/Medi Cal programs strongly preferred.
• Communication and ability to explain complex topics (verbal and written)
• Courteous and professional communication, collaboration, and ability to work with all levels of the organization and Health Plans.
• Excellent analytical, time management, leadership, and interpersonal skills.
• Focus on service with excellent time management, organizational, analytical, and interpersonal skills.
• Advanced with Adobe and Microsoft Applications. (Outlook, Word, Excel , Power Point, Project, Share Point, etc.) Intermediate skill set with Tableau.
• Analytical thinking to draw conclusions and critical thinking using logical reasoning to find solutions.
• Technology, system utilization, automation, privacy, and security
• Proficient Project management skills with attention to detail.
• Outstanding communication skills and ability to work with all levels of the organization.
• Sound decision-making ability.

Required Education

• Bachelor’s Degree or equivalent experience required.

Salary Range
$80-90K/year DOE
Please note that this position will have an (up to 8%) annual performance bonus earning potential and offers a full suite of benefits including 6.5% 401k matching.
At Hill Physicians Medical Group, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.
We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!
Additional Information
We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and one of the “Healthiest Places to Work in the Bay Area.” We have an award-winning Wellness Program, and our average tenure is ~8 years. Every person who joins Hill Physicians is coming in as a leader and has the very real potential to grow with the company as we grow. We’re all in it for the long haul and are bought-in to the success and future of our organization.
We’re proud to have been (and continue to be) a pillar of the Northern Californian healthcare community for more than 30 years. Our more than 5,000 primary care physicians and specialists provide high-quality care across the San Francisco Bay, Sacramento, and Central Valley areas.
By adapting to both the demands of the industry and the needs of consumers, we’ve remained stable and profitable, and our service area now ranges from the Pacific Ocean to the Sierra Nevada’s. We’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.
Our culture is guided by core values​ that promote the health and wellness of our employees and communities (health), commitment (accountability), fiscal responsibility (stewardship), teamwork (collaboration), and our dedication to do the right thing (integrity). 97% of employees feel that supervisors and managers “walk the talk”​ and demonstrate our core values. Join us!
Hill Physicians is an Equal Opportunity Employer
Job Type: Full-time
Pay: $80,000.00 - $90,000.00 per year
Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Experience:

• Managed care: 3 years (Required)
• healthcare (health plan) compliance auditing: 3 years (Required)
• Microsoft Excel: 3 years (Required)
• NCQA standards: 3 years (Required)

Ability to Commute:

• San Ramon, CA 94583 (Required)

Ability to Relocate:

• San Ramon, CA 94583: Relocate before starting work (Required)

Work Location: Hybrid remote in San Ramon, CA 94583