Dir, Risk Adjustment Compliance
Company: Kaiser Permanente
Location: Oakland
Posted on: June 19, 2022
Job Description:
Job Summary:
The primary purpose the Director, Risk Adjustment Compliance is to
provide oversight and maintenance of a high-quality, effective,
best practices risk adjustment compliance program to prevent and
detect violations of law and other misconduct and to promote
ethical practices and a commitment to compliance with applicable
federal, state, and local laws, rules, regulations, and internal
policies and procedures. This position plays a key role in
providing direction for the risk adjustment compliance function as
well as maintaining enterprise-wide view of risk adjustment
compliance activities. Risk Adjustment includes the following:
Medicare Advantage, Affordable Care Act (ACA) and Medicaid.
Core Responsibilities
In addition to the key responsibilities listed below, the position
serves as a compliance subject matter expert related to risk
adjustment, including risk adjustment coding, oversees internal and
external audit (RADV) activities related to risk adjustment,
monitors compliance with national risk adjustment policies and
procedures, provides support for teams to stay abreast of the
latest coding/billing developments impacting risk adjustment, and
monitors the accuracy and quality of coding/billing assignments
impacting risk adjustment. Additionally, this position is
responsible for developing the annual risk adjustment compliance
work plan in alignment with business objectives, reviews audit
results, sets the direction for risk adjustment compliance reviews
and focused projects related to audit outcomes, and enforces
compliance and the Principles of Responsibility (KP's code of
conduct).
The Director, Risk Adjustment Compliance demonstrates continuous
learning and maintains a highly skilled and engaged workforce by
aligning resource plans with business objectives; oversees the
recruitment, selection, and development of talent; motivates teams;
prepares individuals for growth opportunities and advancement;
stays current with industry trends, benchmarks, and best practices;
provides guidance when difficult decisions need to be made; and
adheres to performance management guidelines and expectations drive
business needs.
Essential Responsibilities:
- Demonstrates continuous learning and maintains a highly skilled
and engaged workforce by aligning resource plans with business
objectives; overseeing the recruitment, selection, and development
of talent; motivating teams; preparing individuals for growth
opportunities and advancement; staying current with industry
trends, benchmarks, and best practices; providing guidance when
difficult decisions need to be made; and ensuring performance
management guidelines and expectations drive business
needs.
- Oversees the operation of multiple units and/or departments by
identifying customer and operational needs; analyzing resources,
costs, and forecasts and incorporating them into business plans;
gaining cross-functional support for business plans and priorities;
translating business strategy into actionable business
requirements; obtaining and distributing resources; setting
standards and measuring progress; removing obstacles that impact
performance; guiding performance and developing contingency plans
accordingly; and ensuring products and/or services meet customer
requirements and expectations while aligning with organizational
strategies.
- Oversees company compliance activities by ensuring team
members, including external business partners, provide support to
internal and external stakeholders; reviewing and approving
compliance activities; designing strategies for the implementation
of regulations and regulatory changes; ensuring compliance
activities are fully documented; and overseeing the resolution of
compliance issues.
- Directs compliance reporting efforts across multiple business
functions by overseeing the evaluation and summary of compliance
data, audit information, and potential risks and remedies;
identifying and reporting key compliance drivers, liabilities, and
performance indicators (for example, adherence to standards,
incorporation of new regulations) to senior management; and
developing complex presentations to convey key findings to
executive leadership and external business stakeholders.
- Directs compliance investigations across multiple business
functions by overseeing the collection and analysis of quantitative
and qualitative data; conducting interviews on escalated issues as
appropriate; reviewing and evaluating research on key business
issues; and evaluating and recommending corrective action plans for
substantiated allegations.
- Directs programs or compliance components of larger
cross-functional programs by identifying and managing stakeholder
contacts; assembling teams based on program needs and team member
strengths; developing, analyzing, and managing program plans;
negotiating and managing program schedules and resource forecasts;
and managing program financials and deliverables.
- Directs activities associated with continued regulatory
compliance for multiple business functions by monitoring,
interpreting, and designing strategy around regulatory changes;
determining the impact of changes to the business; providing
direction on implementation of changes throughout the business; and
providing regulatory input before and during inspections to
minimize the risks of future non-compliance.
- Directs and oversees the implementation of compliance efforts
by approving compliance requirements; ensuring the assessment of
current state compliance to identify gaps and corrective actions;
overseeing the analysis and development of complex compliance
standards, policies and procedures, and training; and ensuring the
monitoring of ongoing compliance adherence.
Minimum Qualifications:
- Minimum four (4) years experience in a leadership role with or
without direct reports.
- Bachelors degree in Health Care Administration, Clinical, Law,
Public Health, Business or related field and Minimum ten (10) years
experience in health care compliance, health care operations
(quality, risk, etc.), audit, finance, regulatory or public policy
development, investigations, information security, or
insurance/health plan governance or a directly related field.
Additional equivalent work experience in a directly related field
may be substituted for the degree requirement.
- N/A
Preferred Qualifications:
- Five (5) years experience in health plan compliance.
- Five (5) years experience in health plan operations.
- Five (5) years experience working on fraud or white collar
investigations.
- Five (5) years experience working cross-functionally across
departments, functions, or business lines.
- Two (2) years program management experience.
- Five (5) years health care experience.
- Three (3) years supervisory experience.
- Two (2) years experience managing operational or project
budgets.
- Masters degree in Health Care Administration, Clinical, Law,
Public Health, Business or related field.
- JD degree.
- AAPC or AHIMA certification preferred.
- Certified in Healthcare Compliance (CHC) or other equivalent
compliance certification.
PrimaryLocation : California,Oakland,Ordway
HoursPerWeek : 40
Shift : Day
Workdays : Mon, Tue, Wed, Thu, Fri
WorkingHoursStart : 08:00 AM
WorkingHoursEnd : 05:00 PM
Job Schedule : Full-time
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : NUE-PO-01-NUE-Non Union
Employee
Job Level : Director/Senior Director
Job Category : Compliance, Privacy & Regulatory
Department : Po/Ho Corp - Compl Govt Audit and Reimburse - 0308
Travel : No
Kaiser Permanente is an equal opportunity employer committed to a
diverse and inclusive workforce. Applicants will receive
consideration for employment without regard to race, color,
religion, sex (including pregnancy), age, sexual orientation,
national origin, marital status, parental status, ancestry,
disability, gender identity, veteran status, genetic information,
other distinguishing characteristics of diversity and inclusion, or
any other protected status.
Keywords: Kaiser Permanente, Oakland , Dir, Risk Adjustment Compliance, Accounting, Auditing , Oakland, California
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