Job Posting: Develop, implement, and manage a successful managed care compliance program for the Medical Delivery Network, associated Medical Groups, IPAs and independent physician offices including their respective office staff. Such program must meet both regulatory requirements for contracted managed care plans and CSHS standing policies. Essential duties and responsibilities:
Ensure all services provided to Commercial, Medicare and Medi-cal managed care members are in compliance with program regulations, insurance regulations, and regulatory requirements.
Maintain and track laws and regulations, contract documentations, amendments, and various compliance measures pertaining to Commercial, Medicare and Medi-cal managed care.
Develop policies, procedures, and processes to comply with federal program regulations and any applicable state regulations pertaining to Commercial, Medicare and Medi-Cal managed care.
Provide guidance to various departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contract language for Commercial, Medicare and Medi-Cal managed care.
Act as a liaison with health plans and current CSHS departments to ensure both health plan regulations and CSHS policies are met.
Coordinate and act as primary contact for all health plans audits, including overseeing the review for performance management and proper coding.
Develop and monitor compliance with corrective action plans as a result of post-health plan audits and regulatory audits.
Provide required Compliance and FWA trainings for existing and new employees and, as required, non-employees.
Educate CSHS employees on company policies and procedures regarding access to care, the grievance and appeals process, the eligibility process, etc.
Remain updated on all member and provider policy changes made by the health plan and/or the State.
Act as subject matter expert on health care laws/regulations as a compliance resource to CSHS and affiliates, including contracted and employed physician practices.
Aggregate, analyze, and report audit results, identify error trends and root causes, and make recommendations for performance improvements Cedars-Sinai will consider for employment qualified applicants with criminal histories, in accordance with the Los Angeles Fair Chance Initiative for Hiring.
Qualification Requirements/Preferences: Education Certifications/Licensure Experience Physical Abilities Education and Experience:
Bachelors' degree in related field or equivalent experience.
5+ years of compliance experience, preferably in a healthcare environment.
2+ years of Medi-Cal, Medicare or Commercial Managed Care experience.
Experience in the oversight of contract implementation requirements and regulations.
Previous experience demonstrating effective communication with federal and state regulatory agencies preferred.
Experience interacting with federal government agencies is a plus.
Experience in a managed care or insurance environment preferred. Other Qualifications: Must have a broad understanding of the healthcare environment and comprehensive understanding of managed care. Knowledge of PC applications including spreadsheets is required. Must be organized and able to meet ongoing as well as special time deadlines and work under pressure. Ability to work with, Access, Excel and Word. Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public. Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Requires prolonged sitting, some bending, stooping and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports. Work Environment: Normal office environment. Occasional evening or weekend work. Organizational Expectations: Demonstrates behavior that supports the Cedars-Sinai mission. Attends required orientation and training seminars. Meets production standards within established time requirements. Work product and performance meets quality standards. Demonstrates respect and positive interpersonal skills with patients, clients, the public, managers, and co-workers--a team player. Maintains confidentiality of patient care and business matters. Observes time, attendance and dress code standards. Protects the safety of others and of the physical plant and equipment, following institution policies, fire, safety, and infection control regulations.
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scien...tists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.