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AmeriHealth Caritas Director FQHP Compliance in Raleigh, North Carolina

Director FQHP Compliance

Location: Raleigh, NC

Primary Job Function: Compliance

ID**: 21280

Job Brief

Compliance FQHP Leader needed in North Carolina ACA HMO.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .

Responsibilities:

The Director of Compliance serves as the Compliance Officer for the Federally Qualified Health Plan (FQHP) located in North Carolina. This is a required leadership role for the organization. This position presently reports directly to the Vice President, Corporate Compliance and Privacy Officer for the AmeriHealth Caritas Family of Companies. This position is accountable for overseeing compliance activities as well as oversight of fraud, waste and abuse (FWA).

In addition, this position includes the following specific job duties (which should be considered a non-exhaustive list):

  • Chair the FQHP Compliance Committee, including ensuring that all required compliance committee meetings are scheduled, held, and minutes taken of the same.

  • Oversee FQHP’s compliance with program requirements.

  • Responsible for collaborating and facilitating with the Plan to implementing policies, procedures, and practices designed to ensure compliance with the requirements of the Contract.

  • Serves as the point of contact and engagement with HHS, CMS, DOI, state and/or other regulatory entities related to the FQHP product, including compliance with program requirements as well as program integrity activities.

  • Participate in annual and ongoing meetings with with HHS, CMS, DOI, state and/or other regulatory entities related to the FQHP product.

The Director of Compliance is accountable to provide strategic direction and leadership for the development and implementation of compliance policy, procedures, process and control activities, providing oversight of all operating division and subsidiary compliance, privacy, and regulatory functions, and reports to the CEO on day-to-day operations of the Plan and the Plan’s Board of Directors. In addition, he or she possesses the following attributes:

  • Demonstrates a solid understanding of operational processes and controls and monitors the execution of operational changes required by regulations and guidelines associated with FQHPs.

  • Develops compliance methodologies to test established and newly executed operational processes and controls and monitor effectiveness.

  • Proactively identifies process gaps, weaknesses and deficiencies and/or business productivity/efficiency opportunities.

  • Partners with local and corporate counterparts to develop protocols that support the review and assessment of objectives that ensure compliance with local plan and corporate policies and procedures.

  • Develops and monitors metrics and ensures accurate reporting of regional/local compliance information on compliance and potential incidents of FWA reported via the various mechanisms implemented by the organization, including the 24/7 anonymous hotline.

  • Ensures that local compliance related issues and risks are identified, aggregated and reported.

  • Directs ad-hoc compliance assessments/research as requested by the local compliance associates.

  • Aligns and monitors compliance training and education programs.

Education/Experience:

  • Bachelor's degree in a related field or equivalent education and experience required.

  • 5-10 years leadership experience in a compliance role in support of a healthcare/Managed Care Organization preferred.

  • In-depth knowledge of governmental and/or health plan products (MAO, MCO, etc.) with preference of evidenced FQHP compliance leadership experience required.

EOE Minorities/Females/Protected Veterans/Disabled

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