Full Job Description
Under minimal supervision, the Director of Health Plan Compliance works with the Chief Compliance and Audit Officer in the day-to-day operational management of the hospital ethics and compliance program for the Denver Health enterprise. This includes oversight of compliance activities focused in the in Denver Health Medical Plan (DHMP). The Director of Health Plan Compliance, in collaboration with other ECS department leadership, is responsible for coordination and implementation of the enterprise-wide annual risk assessment and work plan and plays an integral role in the development and maintenance of corporate and compliance program specific metrics, scorecards and dashboards. Additionally, the Director of Health Plan Compliance will report findings and recommendations to the Chief Compliance and Audit Officer on the areas where compliance gaps are found based on risk assessment outcomes and industry and government focus areas and will recommend plans of correction and track program progress toward stated plans of correction. This position works with operations leaders, executives, board members, clinical staff, external government agencies and parties and legal counsel when appropriate.
Exercise overall responsibility and authority for developing, implementing, and managing the compliance program for DHMP and including: • Ensuring that the Compliance Program effectively prevents and/or detect violations of law, regulations, policies or the Code of Conduct. • Maintaining an in-depth understanding of organizational Code of Conduct, policies and procedures, as well as relevant federal and state laws, regulations, and health industry best practices. • Exercising good judgement and skill related to research and regulatory interpretation. • Coordinating ECS and operational resources to assure the ongoing effectiveness of the Denver Health Enterprise Compliance program. • Acts as an effective communication conduit with operational leadership regarding the Compliance Program. • Develops and implements corrective action plans, as well as monitors corrective action plans. • Directs operational departments with development and oversight of compliance monitoring activities. • Develops and measures Compliance Program metrics. • Facilitating the development of and overseeing implementation of corrective action plans and monitoring activities specific to identified high risk areas for non-compliance and fraud and abuse; • Assisting in the development of education programs designed to communicate the Code of Conduct and compliance-related policies, to employees and others working with DHMP. • Responding to organizational needs and requests for compliance assistance. • Developing and manage policies and procedures related to compliance, and internal audit, including those related to fraud, waste and abuse, research, audit procedures, corrective action management, and conflicts of interest. • Oversees DHMP compliance staff within the ECS department. • Overseeing the performance of internal audits/reviews/investigations to ensure internal controls are capable of preventing and detecting significant instances or patterns of illegal, unethical, or improper conduct by employees, agents, or others working with Denver Health; • Advising the organization in regards to compliance with policies, procedures, guidelines, standards and best practices. • Supporting and at times overseeing the organizational response to external audits, ensuring timely response, tracking organizational success, identifying areas for improvement, and overseeing the implementation of necessary corrective actions. • Assisting the Chief Compliance and Audit Officer with developing periodic and annual reports to the CEO, Executive Leadership, Board of Directors and Board Finance, Compliance and Audit Committees on matters involving the Compliance Program. • Coordinate as appropriate with Legal Counsel, conducting or authorizing and overseeing investigations of matters that merit investigation, including investigations conducted under attorney-client privilege, and making appropriate recommendations as to whether such investigations should be done internally or externally, depending upon the issue and available resources. Oversee appropriate follow-up to investigations and other issues generated by the Compliance Program, including development of corrective action plans as needed. Track all issues referred to Enterprise Compliance Services. • Coordinates with selected Legal Counsel (internal or external) as necessary to research and make recommendations regarding compliance with state and federal regulations. • Serving as the ECS Compliance Resource and Liaison for DHMP. • Cooperates with federal and state entities in any compliance program audits, inquiries or investigations. • Assist the Chief Compliance and Audit Officer in the development and implementation of the annual compliance work plans, including delegation of activities to the compliance team. • Represent Enterprise Compliance Services on appropriate Denver Health committees and chairs the DHMP Compliance Committee. • Coordinate or oversee compliance activities with other departments and sources as necessary. • Other duties as assigned by the Chief Compliance and Audit Officer and/or CEO.
s, regulations, and health industry best practices. • Exercising good judgement and skill related to research and regulatory interpretation. • Coordinating ECS and operational resources to assure the ongoing effectiveness of the Denver Health Enterprise Compliance program. • Acts as an effective co
Knowledge, Skills & Abilities
Demonstrated effectiveness operating in complex organizational environments. • Background in Medicare Part C and D and Medicaid HMO regulations are a plus. • Significant experience in the health insurance industry, with specific ethics/compliance program experience or legal experience in a health plan setting are preferred. Knowledge, Skills and Abilities • Excellent organizational and analytical skills. Ability to work well both independently and with others in a matrix environment. • Strong project management skills and experience. • Strong acumen and understanding of healthcare, healthcare regulations, laws and governmental compliance program guidance. • Ability to perform detailed research and online searches of laws, regulations, industry best practices, and governmental guidance that might affect the organization’s compliance practices, and translate regulatory requirements into terms readily understood by audiences at various levels of the organization and external clients. • Ability to effectively present and represent the organization’s interests externally with regulators. • Ability to effectively present information and respond to inquiries from employees, regulatory agencies, and others, as necessary. • Must have excellent data analysis and communication skills (verbal and written). • Strong analytical and organizational skills as well as problem-solving capabilities. • Ability to manage a diverse and demanding workload. • Ability to deal with a variety of abstract and concrete variables. • Strong and reliable judgment and discretion required. Strong ability to independently and self-sufficiently identify, navigate and successfully resolve various compliance, risk management and regulatory issues. • Strong computer skills and knowledge of MS Office Suite. Computers and Technology 1. Strong computer skills and knowledge of MS Office Suite. 2. Experience with claims systems, SmartSheets, and Lawson preferred. Certificates, Licenses and Registration Certified Compliance professional (CHC, CHRC or CCEP) or other nationally recognized certification preferred. All Certifications and Licenses required for this job must be kept current as a condition of continued employment. Supervisory Responsibilities This position will be responsible for, but not limited to, hiring, terminating, performance management, coaching, supervision, fostering teamwork, training and development of one or more employees.
Bachelor’s degree required. Relevant graduate degree (Juris Doctor or Master’s degree in a related field) preferred.
Five to eight years’ experience in health plan or healthcare compliance, law/regulations preferred
Credentials, Computer and Technology
1. Strong computer skills and knowledge of MS Office Suite. 2. Experience with claims systems, SmartSheets, and Lawson preferred. Certificates, Licenses and Registration Certified Compliance professional (CHC, CHRC or CCEP) or other nationally recognized certification preferred. All Certifications and Licenses required for this job must be kept current as a condition of continued employment. Supervisory Responsibilities This position will be responsible for, but not limited to, hiring, terminating, performance management, coaching, supervision, fostering teamwork, training and development of one or more employees.
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 18 school-based health centers, Rocky Mountain Poison and Safety, a Public Health department, an HMO and The Denver Health Foundation.
As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.
Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. As an EOE, Denver Health does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
125,900.00 – 195,200.00 a year