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Job Description Summary:
The Compliance Advisor, provides direction and oversight with respect to the compliance activities for OhioHealthy Medical Plan. The Compliance Advisor is responsible for:
- Identifying and assessing areas of compliance risk and participating in the annual Ethics & Compliance Program Risk Assessment.
- Collaborating with stakeholders to effectively incorporate the OhioHealthy Medical Plan compliance needs within the system operations and programs
- Monitoring compliance with payer (Commercial, Medicaid, Medicare, Medicare Advantage) contracts, and regulatory requirements
- Working with stakeholders to design and implement processes for stakeholders to track & audit services provided to OhioHealthy Medical Plan.
- Auditing OhioHealthy Medical Plan compliance with Clinical Integration requirements
- Working with stakeholders to develop bylaws, policies and procedures around network management and processes to store confidential data (ie. Provider Scorecard info, Provider Information- Agreements, etc)
- Developing and implementing compliance education for OhioHealthy Medical Plan as appropriate
- Managing incident response and open lines of communication for OhioHealthy Medical Plan as appropriate including the ACO’s anonymous reporting mechanism
- Other compliance duties as assigned
Requires a BA/BS; at least 6+ years of health care, regulatory, ethics, compliance or privacy experience; or any combination of education and experience, which would provide an equivalent background. Health plan compliance experience is required
Experience with federal and/or state regulations and compliance oversight in health care. The ability to comprehend and interpret regulatory, legislative, and contractual mandates. Experience with Medicare Advantage
MS/MBA/JD or professional designation preferred.
Making Health Care Better
ACHP is the voice of a unique approach in health care today, one that puts the patient at the center with plans and clinical teams collaborating to improve health outcomes and reduce costs. Our advocacy focuses on providing policymakers with tested solutions, rooted in a model that is proven to deliver better value for patients, employers and taxpayers.