Compliance Manager, FT
The Compliance Manager is responsible for monitoring, analyzing, documenting, communicating, and educating on all regulatory requirements affecting FRHS operations, and working with the affected department(s) to modify operations and policies and procedures to ensure compliance.
• Monitor new laws and regulations to identify those that may be applicable to Medicaid, Medicare, and Commercial compliance
• Research, inform, and educate business and compliance operations of all new and updated regulations and guidance.
• Advise on implementation and execution of regulations and guidance. Review internal policies to confirm alignment with regulatory requirements.
• Support and coordinate responses to client requests for special reporting needs related to NCQA, HEDIS, CMS and other data requests
• Manage compliance reporting processes that provide timely and relevant information on all pertinent aspects of Medicaid, Medicare and commercial compliance issues
• Maintain knowledge of business solutions, systems and processes to effectively analyze and communicate regulatory impacts for implementation activities.
• Conduct business specific analysis, prepare and communicate business impacts summarizing requirements and recommended actions
• Partner with business operations to monitor implementation plans and provide compliance support and recommendations as required.
• Document and track implementation plans, activities and milestones through completion of implementation process
• Participate in remediation and corrective action planning for identified compliance controls and program deficiencies
• Develop and implement educational programs designed to promote awareness and understanding of Medicaid and Medicare and commercial compliance issues, laws and regulations, and consequences of non-compliance
• Keep informed of current vision industry trends and understand impacts related to organizational Medicaid and commercial compliance efforts
• Plans and executions cross-functional collaboration initiatives, as well the development and delivery of compliance training
• Partner with senior leadership on strategic initiatives to ensure compliance with internal policies and procedures and federal and state requirements
• Provide timely and practical advice and support for questions and concerns regarding general compliance activities
• Assists senior leadership in overall management of FRHS compliance program, and serves as a resource and point of contact for FRHS compliance matters. Leads regulatory, audit, billing, coding, documentation, medical necessity and other general compliance processes and analyses that result in appropriate reimbursement for FRHS and adherence to applicable laws, rules, guidelines and regulations.
• Serves as a resource for FRHS compliance via professional development, refining methodologies and improving departmental work products.
• Ensures the accuracy and timely completion of compliance auditing, investigations, reviews and the annual compliance work plan.
• Assists in reviewing and revising policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct. Manages day-to-day operation of the Program.
• Develops and periodically reviews and updates the Business Ethics Policy, Code of Conduct Policy, and other related policies in accordance with current practices and relevance in providing guidance to management and employees.
• Collaborates with other departments to direct compliance issues to appropriate channels for investigation and resolution. Consults with the corporate attorney as needed to resolve legal compliance issues.
• Response to alleged violations of rules, regulations, policies, procedures, and business ethic by evaluating or recommending the initiation of investigative procedures. Oversees the uniform handling of such violations.
• Acts as an independent review and evaluation body to ensure that compliance issues/concerns within the organization are being appropriately evaluated, investigated, and resolved.
• Conducts compliance investigations and perform risk-based compliance audits.
• Manage regulatory and licensure filing processes to ensure submissions are accurate, complete, and timely. Provide support and quality assurance for filing activities performed by others.
• Assist in preparing and presenting periodic update reports of compliance vulnerability, risk, and progress of compliance efforts to senior leadership.
• Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of compliance hotline; (b) heightened awareness of Business Ethics Policy and training, and (c) understanding of new and existing compliance issues and related policies and procedures.
• Develops effective compliance training, including appropriate introductory training for new employees as well as ongoing training for all employees and managers.
• Monitors the performance of the Compliance Program and related activities on a continuing basis, taking appropriate sets to improve its effectiveness.
• Experience and expertise in auditing, billing, coding, proper documentation, medical necessity evaluation and general compliance processes, including regulatory and governmental payer regulations and requirements, are required.
• Experience and expertise in research, findings analysis and report writing.
• Must be familiar with a variety of the field's concepts, practices and procedures; perform a variety of compliance tasks relying on experience and judgement to plan and accomplish goals.
Education and Experience:
• Bachelor’s degree required
• Preference for Master’s degree and compliance certification such as CHC or CCEP.
• Minimum three (3) years of experience in compliance, audit, legal or equivalent field
• Knowledge and experience in the health care and 340 B prescription process
• Experience responding to or performing Medicare, Medicaid and other governmental or regulatory audits, investigations or inquiries that impact FRHS, hospital charging, documentation, clinical coding and billing procedures, medical records, medical necessity required.
• Requires excellent verbal and written communication skills.
• Must be organized, versatile and able to work independently.
• Proficiency in Microsoft Office, Word, Excel, PowerPoint
Paula Cape - Recruiting / Onboarding Coordinator
1201 South Dakota 71
Hot Springs, SD 57747
Phone: 1-605-745-8910 ext.2141