COMPLIANCE OFFICER - CountyCare

Job Summary

The Compliance Officer, CountyCare reflects the mission and vision of Cook County Health (CCH), adheres to the organization’s Code of Conduct and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines, and all other regulatory and accreditation standards.

The Compliance Officer, County Care is responsible for the ongoing development, implementation, maintenance, and evolution of the CCH Health Plan compliance program and all related compliance activities. This includes, but is not limited to, the development and subsequent assessment of comprehensive policies and procedures, protocols, compliance training, and internal investigations.

General Administrative Responsibilities

Collective Bargaining

• Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
• Participate in collective bargaining negotiations, caucus discussions and working meetings

Discipline

• Document, recommend and effectuate discipline at all levels
• Work closely with labor relations and/or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
• Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements

Supervision

• Direct and effectuate CCH management policies and practices
• Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements

Management

• Contribute to the management of CCH staff and CCH systemic development and success
• Discuss and develop CCH system policies and procedures
• Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary: hire, transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements
• Work with Labor Relations to discern past practice when necessary

Typical Duties

• Governs of the Health Plan’s Fraud, Waste, Abuse (FWA) and Financial Misconduct Program (Program Integrity Program) including delegated Special Investigations Unit (SIU) to ensure that Program Integrity Program and FWA initiatives are actively administered and addressed, as delegated by the Chief Corporate Compliance & Privacy Officer

oImplements and coordinates communication protocols and methods that encourage CCH workforce/employees, independent contractors, and delegated vendors to report issues related to noncompliance and FWA without fear of retaliation

oCoordinates and oversee fraud investigations and referrals conducted by delegated SIU’s, where applicable

oCollaborates with other Medicaid health plans, HFS, the HFS Office of Inspector General, Medicaid Fraud Control Units (MCFUs), local law enforcement, commercial payers, and other organizations, where appropriate, when a potential FWA issue is discovered that involves multiple parties.

oEnsures that FWA is reported in accordance with federal, state and local requirements, as well as the guidelines in the Medicaid Managed Care regulations at 42 CFR §438.608 and the CCH Managed Care Community Network (MCCN) Agreement with Illinois Department of Healthcare Family Services (HFS)

• Serves in a leadership capacity to develop the Health Plan compliance program in conjunction with the Chief Corporate Compliance & Privacy Officer
• Chairs and facilitates the executive Regulatory Compliance Committee meeting on a quarterly basis
• Develops, implements, maintains, and assesses/updates compliance policies and procedures to ensure adherence with relevant regulatory and requirements
• Modifies health plan policies, procedures, and projects to reflect changes in laws and regulations
• Establishes a structured process for regulatory review, monitoring, and dissemination of information
• Reviews health plan agreements, contracts, addenda, and other relevant documents, as needed
• Oversees, directs, delivers, tracks, or ensures delivery of compliance training and communications, both general in nature and specialty, for employees, workforce, network providers, vendors, and consultants
• Aligns with Health Plans’ operations regarding sanction/exclusion checks to verify that CountyCare network providers, employees, workforce, vendors, and consultants (where necessary) are screened against applicable Federal and State sanction and exclusion lists
• Coordinates with Health Plan provider network contracting to ensure new providers undergo a FWA review
• Establishes and administers a process for receiving, documenting, tracking, investigating, and taking action on all compliance concerns

oInvestigates reports of alleged non-compliance to determine the validity, nature and scope of the report in conjunction with the designated team members, as identified by the Chief Corporate Compliance & Privacy Officer

oPerforms interviews with key personnel to validate compliance with established policies and procedures and applicable regulations in conjunction with reports of alleged non-compliance, as deemed necessary

oDevelop reports upon completion of each compliance review, which details recommendations designed to correct any potential weaknesses or areas of non-compliance discovered during the review

oPerforms follow-Up reviews to ensure action plans have been adequately implemented

oCollaborates with operational areas to remediate concerns through action plans to correct potential weaknesses and assure ongoing compliance

• Develops and coordinates compliance projects with CCH entities, which may be ad-hoc or delineated in the Compliance Program Annual Work Plan and perform prospective reviews in conjunction other personnel as deemed necessary, and as requested by the Chief Corporate Compliance & Privacy Officer
• Develops vendor-specific annual audit protocols, performs audits, review results, and determines if regulatory and requirements requirement are met
• Produces and delivers Compliance Program reports for CCH and Health Plan Leadership, , the Board of Directors, and/or the Audit and Compliance Committee of the Board of Directors, as directed by the Chief Corporate Compliance & Privacy Officer
• Collaborates with Health Plan Leadership to facilitate operational ownership of compliance
• Monitors operational management of the Health Plan complaint, grievance, appeals and fair hearing processes for program compliance including review of trends and patterns through reports and data analysis
• Maintains highest levels of confidentiality regarding all departmental operations in both verbal and written and with the use of technology
• Works with minimal supervision and use time effectively
• Maintains a high degree of follow-through despite frequent interruptions
• Performs other duties as assigned

Reporting Relationship

Reports to the Chief Corporate Compliance & Privacy Officer

Minimum Qualifications

• Master’s degree from an accredited college or university
• Three (3) years of conducting complex healthcare analysis and/or investigations
• Leadership competencies to include planning and organizing, problem solving, informing, consulting, supporting, and networking
• Knowledge of coding, billing, medical records, review/analysis, and documentation

Preferred Qualifications

• Master’s degree or higher in Healthcare, Business, Education, or related field from an accredited college or university
• Juris Doctor (J.D.)
• Professional Registration/Certification or compliance/fraud related healthcare credentials, current & active, including but not limited to RHIA, CPA, CFE, AHFIm CFE, HIA, HCAFA, MHP or CHC
• Project Management experience
• Five (5) years recent managerial/supervisory experience in a health plan, hospital or a large multi-specialty clinic setting with experience in the areas of compliance, audit, risk, quality and/or legal
• Health plan experience

Knowledge, Skills, Abilities and Other Characteristics

• Knowledge and experience with extensive report development and policy and procedure development
• Knowledge of Health Care Regulatory standards
• Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
• Familiarity with public speaking and business presentations
• Strong working proficiency with Microsoft Office (Access, Excel, PowerPoint, and Word)
• Demonstrate analytical and organizational, problem-solving, critical thinking, and conflict management/resolution skills
• Demonstrate attention to detail, accuracy, and precision
• Behavioral commitment to quality work and customer service philosophy
• Ability to work in a fast-paced environment, which requires handling multiple tasks at once
• Ability to maintain a professional demeanor and composure when challenged
• Ability to function autonomously and as a team member in a multidisciplinary team
• Ability to travel to and from any CCH locations, including the Ambulatory & Community Health Network Clinics

Physical and Environmental Demands

This position is functioning within a healthcare environment.The incumbent is responsible for adherence to all hospital and department specific safety requirements.This includes but is not limited to the following policies and procedures:complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.

FILING.

“Degrees awarded outside of the United States with the exception of those awarded in one of the United States’ territories and Canada muse be credentialed by an approved U.S. credential evaluation service belongings to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview”.

*Please note all offers of Employment are contingent upon the following conditions: satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.

*CCH is strictly prohibited from conditioning, basing or knowingly prejudicing or affecting any term or aspect of County employment or hiring upon or because of any political reason or factor.

COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER.