Compliance Investigator II

The Regulatory Affairs Specialist II has demonstrated competencies in supporting the plan-wide regulatory affairs and compliance program, including activities related to HIPAA, Fraud, Waste, and Abuse (FWA), and compliance issues. As such, conducts investigations to effectively prevent, detect, and mitigate healthcare FWA, privacy and compliance issues. Supports daily operations of the Regulatory Affairs unit by ensuring deliverables and all case management performance metrics are met for assigned cases. This position serves as an investigative liaison between the plan and our regulatory agencies and internal departments.

• Proficiently performs all duties of the Regulatory Specialist, independently.
• Structures and successfully completes investigations independently including writing formal investigative reports for privacy, FWA, and compliance matters. In doing so, exercises, professional judgement and escalate matters to leadership, as needed.
• Independently conducts investigative interviews, maintaining complete and accurate records.
• Prepares formal records and reports in response to enforcement agency requests to support investigations, which may include, but not be limited to the Department of Justice and Department of Medi-Cal Fraud and Elder Abuse. Demonstrates proficiency and professional acumen when interfacing with external stakeholders on behalf of the Plan.
• Works directly with DHCS Privacy Office to report privacy related incidents, provide updates upon request, ensure timely filing requirements are met for all reports and follows up on pending cases to confirm cases are closed with the DHCS Privacy Office.
• Responsible for identifying trends and linking related cases to assist with trending patterns and maintaining accurate data for daily, monthly, quarterly, and annual privacy and FWA analytics, including those fraud cases referred for recoveries.
• May provide input regarding controls for monitoring fraud-related issues within the business units. 
• As directed by manger, performs quality assurance case reviews to ensure they meet DHCS requirements, regulatory, and Partnership professional standards.
• Ability to serve as regulatory affairs expert to support complex regulatory inquiries and responses to regulatory agencies.
• Encourages continuous awareness and education of unit staff, which may include development and maintenance of training materials
• Manages daily case load, prioritizing appropriately, and making recommendations to leadership to ensure the timely submission of privacy and FWA cases to DHCS
• Demonstrates proficiency in Manages the intake and ongoing maintenance of referral/inquiry platform
• Ability to assess, facilitate, and see to completion, referrals and inquiries, of varying complexity and scope, submitted to RAC
• Monitors unit tracking systems to ensure the timeliness of deliverables are met, making recommendations for improvements in tracking and/or work flows as necessary
• Competence in assessing and analyzing unit work consistent with established criteria and providing recommendations and as directed by manager, provide coaching to unit staff as needed
• Maintains awareness and understanding of regulatory requirements that govern unit responsibilities
• Makes strategic recommendation(s) to improve the accuracy, quality, and/or reporting of cases to enhance HIPAA, FWA, and compliance issues cases
• Assists Regulatory Affairs Manager with developing, maintaining, and delivering compliance training program including but not limited to:
  • Updating new hire compliance trainings and annual training materials
  • Making recommendations for focused department trainings based on trends and conducting targeted department trainings ▪
  • Works with departments on resolving complex regulatory required submissions
  • Assists Regulatory Affairs Manager with preparing materials and presentations for PTAS and FWA Subcommittees 

Education and Experience

Bachelor’s degree in relevant field preferred or equivalent combination of education and experience; minimum of two (2) years’ experience as a Regulatory Affairs Specialist or relevant experience in managed care with knowledge of the Medi-Cal, and NCQA requirements, Medicare and Knox Keene. Experience with the investigation and reporting of HIPAA,FWA, and compliance issues related incidents.

Special Skills, Licenses and Certifications

Highly proficient in applicable business software applications including PC usage, Microsoft Word, PowerPoint, Excel, Project, typing speed of 30 wpm. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business

Performance Based Competencies

Excellent oral and written communication skills. Excellent organizational skills with ability to prioritize assignments, maintain effective filing systems, and meet deadlines. Ability to work under minimal supervision and exercise independent judgment. Diplomacy and tact in handling sensitive information regarding personnel affairs as required. Ability to interact with executives and vendors effectively, handling all assignments with efficiency. Must be able to handle multiple tasks and meet deadlines. Excellent judgment.

Work Environment And Physical Demands

Ability to use a computer keyboard and other business machines. More than 50% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying sizes, weighing up to 35 pounds. 

HIRING RANGE:

$96,970.04 - $121,212.56

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.