Job Description

Job Description

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

Applicants for this role will have the flexibility to work remotely anywhere in Continental United States.

Position Purpose:
Provides strategic leadership and management of department overseeing compliance with regulations and laws related to Risk Adjustment across our Marketplace, Medicaid and Medicare lines of business, which includes implementation of elements of an effective compliance program. Oversee the development of risk assessments oversight and the monitoring work plans pertaining to Risk Adjustment. Partners with business areas to ensure and implement effective prevention, detection and correction of compliance issues.

• Establishes and maintains a process for overseeing compliance with regulations and laws related to Risk Adjustment requirements.
• Provides guidance to various business departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contractual language.
• Conducts compliance reviews and manages team that conducts compliance reviews, assisting with identification of issues and collaborating with Corrections team for remediation of issues.
• Performs risk assessments and report emerging trends, deficiencies and variances, report findings to other departments and teams as appropriate.
• Ensure sufficient monitoring activities to assist with prevention and proactive identification of compliance concerns.
• Develops and monitors metrics and other oversight tools that indicate business area compliance.
• Provides compliance guidance, direction, and compliance risk assessment to assigned business partners.
• Plans and collaborates with other teams and leaders on complex projects/programs necessitating the origination and application of new and unique approaches.
• Sets operational priorities including the development and maintenance of effective oversight activities and prioritization of work.
• Responsible for Board and Executive reporting related to responsibilities of the team and compliance of business operations for which you oversee.
• Educates, encourages, and assists those within the company to maintain integrity through correction of identified non-compliance in order to meet the requirements of Government-sponsored health care programs.
• Participates in mock and actual CMS and other regulatory audits and coordinates with Internal Audit, Regulatory Compliance and/or Market based Regulatory Affairs on responses to agency inquiries and oversees the internal and external processes required to ensure the Company maintains a consistent state of Audit readiness.
• Maintains a current working knowledge of various laws, regulations, and industry guidance that impacts the health industry generally, and government programs in the health sector specifically, including fraud and abuse and anti-kickback statutes, OIG and government health plan guidelines and state marketing compliance laws, prompt pay, provider adequacy and other laws.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience:

• Bachelor’s Degree in Business Administration, Public Policy, Public Health, Health Administration, related field, or equivalent experience required. Master's Degree CPA, CISA, JD, MHA, MBA, MIS or equivalent experience preferred
• 10+ years Compliance experience, preferably in a healthcare environment, or equivalent experience preferred
• 4+ years Management experience preferred
• 4+ years’ Experience with risk adjustment processes, procedures, and oversight of same preferred

Licenses/Certifications:

• HCCA certification (CHC) or equivalent preferred

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Job Tags

Similar Jobs