Purpose of Role

The Compliance function implements and administers programs, policies, procedures, and practices to ensure that Canopy Health complies with federal, state and local health care regulations and NCQA standards.  The Compliance team acts as a liaison to government agencies by coordinating onsite external regulatory audits, monitoring industry trends and requirements, and providing ad hoc reporting and documentation.  In addition, the team also supports internal and external audits, prepares reports, responds to inquiries from all stakeholders, including the DMHC and parent plan partners, facilitates the resolution of corrective action plans, and communicates findings to internal Committees and staff. The team also provides oversight to our participating Medical Group/IPA partners and other medical care providers which includes overseeing audits, collecting reports, and issuing corrective action plans to resolution.  The Compliance Manager will be called upon to ensure successful management of these activities under the direction of the Compliance Officer.

PRINCIPAL ACCOUNTABILITIES

1.    Actively contribute to the administration, maintenance, and improvements of the Canopy Health compliance program.  In collaboration with the Compliance Officer, serve as a point of contact for the Canopy Health compliance program, and work in collaboration with Canopy Health leaders to implement a thorough compliance program across all Canopy Health departments.

2.    Support the execution and administration of Canopy Health’s delegation oversight activities in collaboration with the Compliance Officer. This includes overseeing delegated functions, including utilization management, complex care management, credentialing, claims and provider dispute reports. Oversight activities include, and are not limited to, collection of regulatory reports, audit and corrective action plan management.

3.    Support the execution and administration of Canopy Health’s delegate responsibilities to parent plan partners in collaboration with the Compliance Officer. This includes providing required reports, policies and procedures and resolving any deficiencies identified during the audit process.

4.    Support the execution and administration of Canopy Health’s restricted Knox-Keene compliance responsibilities to the Department of Managed Health Care, and any future regulatory agencies. This includes submission of ongoing reports, such as MTRs and PDRs, filings of regulatory items, including updated policies and procedures, participation in medical and financial audits and coordinating with the Compliance Officer for other regulatory requirements.

5.    Manage compliance team member(s) to ensure deliverables are met while  achieving high levels of satisfaction both with customers and team members.  Work directly with the Compliance Officer to screen and hire appropriate candidate(s) and provide first-line managerial support to them.   Ensure assignments are communicated clearly to each team member, results are tracked and measured, and delivery of outcomes are timely and complete.  Provide direct feedback to each team member to ensure their potential is being developed through coaching and exposure to other Canopy Health leaders.  Reward high performers.

6.    As directed by the Compliance Officer, develop policies and procedures to ensure Canopy Health is adhering to appropriate regulatory guidelines and practices.  As guidelines change, coordinate with the appropriate business owner to support timely updates of the Policies and Procedures to ensure overall compliance.

7.    Ensure adequate documentation of policies and procedures including revisions and revision history, regulatory submissions, and audit documents and artifacts is maintained and accessible in a well-organized repository.

8.    Develop, maintain and manage a Canopy Health calendar and set of project plans for regulatory submissions and audits in support of operational leaders contributing to our Compliance activities. As necessary maintain project plans for corrective action plan mitigation including timely notifications and due date reminders to contributors to those plans.

9.    Collect and review relevant compliance-related data, conduct analyses, and, in areas where Canopy Health is not in compliance determine mitigation approaches.  Work with internal and external staff to provide recommendations to the Compliance Officer that will ensure compliance standards are met.

10.  Under the direction of the Compliance Officer, develop and implement internal audit processes within Canopy Health departments.  Based on the various regulatory audit frameworks, develop a process and then conduct internal audits of the regulatory standards.  Provide a report of all findings, and recommend action plans to help mitigate any areas of concern found during these internal audits.

11.  Work with all Canopy Health departments as well as external staff to develop and gain approval for a recommended set of controls in areas where deficiencies have been found, whether during an internal or external audit, or even when controls do not seem to be in place after a general review of an area.

12.  Coordinate, compile, and report compliance activities with the health plans and delegated entities (IPA’s and MSO) to the Compliance Officer to ensure appropriate actions are being taken by each party.

13.  Develop compliance-related communications as directed for staff, partners, and regulatory agencies.

14.   Participate in the development and implementation of appropriate Fraud, Waste, and Abuse training with all Canopy Health staff.

15.   Contribute, and as directed take accountability, for progress on all goals and objectives related to the Canopy Health compliance program.

16.   Identify and compile reports of compliance vulnerability that enable the Compliance Officer to communicate a clear message to Canopy Health leaders around all risk areas.

17.   Along with the Compliance Officer, understand current regulatory environment and ensure appropriate changes are made to the Canopy Health compliance program, as needed.

18.   Any other duties as required to ensure Canopy Health Compliance accountabilities are fulfilled.  Ensure the privacy and security of PHI (Protected Health Information) as outlined in Canopy Health’s policies and procedures relating to HIPAA compliance

Experience

5-7 years experience working in the managed care field for the provider (Medical Group), payer (Health Plan), or a regulatory agency with a focus on health care. Essential to have experience in health care compliance, a strong analytical skill set, and experience with regulators like DMHC and CMS.

Education/License:

Bachelor's degree or equivalent work experience required. Master's degree required.

Knowledge/Skills Required:

Demonstrated experience in providing leadership for a compliance function within health care. Strong organizational, analytical, and strategic-thinking skills. Understanding of Six Sigma or other process improvement methodology is a plus.

Must support a culture of collaboration; must have excellent writing, interpersonal communication, organizational skills; and sensitivity to a multi-cultural environment and community.