Associate Compliance Officer in Pasadena, California at Imperial Management Administrators Services Inc

JOB TITLE: Associate Compliance Officer FLSA STATUS: Exempt

DEPARTMENT: Compliance

REPORTS TO: Compliance Officer

JOB SUMMARY: The Associate Compliance Officer in conjunction with the Compliance Officer is responsible for the development, implementation, operation, and monitoring of the Compliance Program to ensure regulatory requirements.

1. Alongside the Compliance Officer embody and promote an overall culture of compliance that encourages ethical conduct and a commitment to compliance with the law.

1. Management of Compliance Department alongside the Compliance Officer
   • Oversee and monitor implementation and effectiveness of the Compliance Program, including through supervision of direct employees who assist in Compliance Program efforts.
   • Develop the Compliance Committee.
   • Managing the Compliance Department, including management of the Compliance Program to ensure that compliance goals are met and that resources are used effectively.
2. Compliance Committee Involvement alongside the Compliance Officer
   • Oversee the Compliance Committee, including scheduling meetings, developing appropriate agendas (with a standing FWA agenda item), compiling reports and information as requested by the Compliance Committee, and maintaining meeting minutes.
   • Presenting the findings of any internal or external audit at the first regularly scheduled Compliance Committee meeting after the conclusion of the audit, or sooner, as necessary.
   • Staying abreast of evolving CMS and other compliance program expectations.
   • Making reasonable efforts to stay abreast of current and evolving legal and program standards through review of regulatory and other materials, publications, websites, and guidelines (including Health Plan Management System memoranda) issued by CMS or other relevant government agencies.
3. Internal Reporting Responsibility alongside the Compliance Officer
   • Reporting frequently, as necessary and appropriate, to the CEO, legal counsel and the Compliance Committee on compliance issues and the status of the Compliance Program, unless such reporting would compromise an ongoing investigation or other confidential information.
   • Reporting on a regular basis, at least quarterly, or more frequently as necessary, to the Board of Directors on the implementation and effectiveness of the Compliance Program.
   • Such reports shall contain an update concerning the activities and status of the Compliance Program, including, without limitation (a) the status of compliance training when relevant, (b) issues identified, investigated, and resolved by the Compliance Program, (c) state or federal audits or enforcement activity, (d) a summary of monitoring and auditing activities, and (e) a description of FWA activities. The Associate Compliance Officer will, in conjunction with the Compliance Officer and the Compliance Committee, provide the results of its annual readiness and risk assessment to the Board of Directors.

• Policies and Procedures/Code of Conduct alongside the Compliance Officer
  • Develop written Compliance Program policies and procedures that meet CMS regulatory and other requirements and are designed to (a) implement an effective Compliance Program; and (b) address existing and new compliance risk areas.
  • Working with senior management as appropriate, to ensure that operational policies and procedures contain effective internal controls designed to prevent and detect significant instances or patterns of illegal, unethical, or improper conduct or FWA.
  • Periodically reviewing, modifying, and amending (or working with others to modify and amend) the Compliance Program, including the Code of Conduct and the Compliance Program policies and procedures, as necessary and presenting the same for Board of Director approval when appropriate.
• Education and Training alongside the Compliance Officer
  • Create, coordinate, and appropriately document education and training programs relating to the Compliance Program and FWA prevention, detection, and correction programs, and review and updating such education and training programs as necessary, but at least annually.
  • Develop and implement mechanisms for testing the effectiveness of relevant education and training programs as directed by CMS or other oversight bodies.
  • Work with senior management and FDRs, as appropriate, to ensure that these individuals and entities and their staff have the requisite information and knowledge concerning program requirements to carry out their responsibilities in a lawful and ethical manner, including through appropriate specific training.
• Communication Regarding the Compliance Program alongside the Compliance Officer
  • Appropriately publicizing the existence of the mechanism for reporting suspected instances of non-compliance (e.g., via periodic emails to employees or FDRs, posting the information in prominent common areas, brochures, intranet, and internet).
  • Developing and implementing methods and programs that encourage the asking of compliance related questions and the reporting of suspected fraud, misconduct, and other non-compliance, including through anonymous and confidential good faith reporting of potential non-compliance or FWA through the compliance hotline, without improper retaliation.
  • Develop and implement systems to ensure that member compliance related issues are appropriately directed to the Compliance Department for consideration and/or investigation.
  • Respond appropriately to compliance with questions and inquiries.
• FWA Prevention, Detection and Correction Program and Related Matters alongside the Compliance Officer
  • Conduct ongoing FWA risk assessments to direct activities towards high-risk areas.
  • Work with appropriate senior management to institute specific measures to detect, correct and prevent FWA, including through conducting proper internal monitoring, auditing, and oversight of those areas at greatest risk of FWA.
  • Monitor the effectiveness of the FWA program for all subsidiaries, consistent with the program requirements.
  • Oversee the communications with, and reporting to, CMS and its relevant designees, other oversight bodies or law enforcement, as appropriate, regarding compliance issues.
  • Coordinate potential FWA investigations/referrals with the appropriate National Benefit Integrity Medicare Drug Integrity Contractor or other appropriate governmental or other law enforcement entities, particularly where the potential FWA issue identified appears to affect multiple payers.
• Employment and Disciplinary Matters alongside the Compliance Officer
• Coordinate with the Human Resources Department and others, as appropriate, to ensure that the OIG and GSA exclusion lists are checked with respect to new hires, employees, officers, directors and FDRs to confirm that such individuals and entities are not on such lists, pursuant to specific policies and procedures.

• Work with the Privacy Officer to address the handling of health care privacy and security related issues relating to members and to ensure appropriate reporting to CMS and other appropriate government agencies.

1. Assess Overall Effectiveness of the Compliance Program alongside the Compliance Officer
   • Assess the overall effectiveness of the Compliance Program in an Annual Readiness and Risk Assessment, and taking steps to revise the Compliance Program based on information learned in furtherance of continual process improvement.
   • Orchestrate cooperative efforts between business units to ensure that compliance issues are addressed as efficiently and effectively as possible, with an focus on continuous process improvement.
2. Consult Legal Counsel and Related Matters alongside the Compliance Officer
   • Consult with legal counsel for legal advice and guidance, as appropriate.
   • Periodically review (or assist in reviewing) template contracts between the plan and clinical or administrative FDRs to ensure arrangements comply with relevant laws, regulations and program requirements, as applicable.
3. Data Submission alongside the Compliance Officer
   • Oversee the submission of all validated Part C data received from internal business units and FDRs, and validated Part D data received from internal business units and FDRs (particularly the Pharmacy Benefit Management entity).
   • Oversee and monitor the submission of validated Part C and Part D data to ensure compliance with CMS data submission requirements, deadlines, and technical specifications.
   • Manage the annual Part C and Part D data validation audit conducted by an auditor that meets CMS qualifications.
   • Monitor controls data submission. (This shall include periodic random checks, as directed at the Compliance Officer's discretion, of enrollment, appeals, grievances, utilization management, claims, encounter data, Part D data, and other data to assure accuracy, completeness, and truthfulness to the best of the company's knowledge, information and belief).
   • Periodically review (and assist senior management in updating) the procedures for the submission of data to CMS to ensure that adequate controls have been put in place to promote the submission of accurate data in compliance with CMS reporting requirements.
4. Annual CMS Service Area Expansion (SAE), New Market and Special Needs Plan (SNP) Application Submission Process alongside the Compliance Officer
   • When applicable, lead and oversee the submission for approval of annual SAE, new market and SNP applications according to CMS requirements, deadlines and technical specifications of the plan applications.
   • Obtain and maintain state certifications of authority to operate in all states where the plan are licensed.

1.Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations and IMAS’s Standards of Conduct.

1. Fosters appropriate communication and relations with Supervisor, co-workers and other staff.

Plan.