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About Clever Care Health Plan

Clever Care Health Plan is a newly founded Medicare Advantage health plan serving Medicare beneficiaries in Southern California. Our employees are passionate in providing best services to our members and healthcare providers. Our three office locations are in Arcadia (Los Angeles County), Huntington Beach (Orange County) and New York City.

Job Summary

  • The Audit & Compliance Officer (ACO) is a key member of health plan’s senior leadership team, reports directly to the Clever Care’s Board of Directors and dotted-line to the Chief Executive Officer.
  • The ACO is responsible for overall company’s compliance to federal and state regulations (e.g., CMS, CA DMHC, DOI). The ACO will collaborate and support sales/brokers, providers/vendors, FDR (First-tier, Downstream, Related entities), finance, IT and operations teams to successfully pass regulatory audits. The ACO also serves as the Medicare Compliance Officer and HIPAA Privacy Officer.
  • The ACO is a full-time employee, is employed by the Plan. Competitive compensation with medical & dental insurance benefit, 401k matching with immediate vesting, and generous PTO days/year (in addition to 10 national holidays).

Functions and Job Responsibilities

This position is responsible to:

  • Establish and maintain an effective compliance program, compliance policies and procedure in accordance to federal/state/county regulatory requirements to prevent, detect and correct non-compliance and identify potential fraud, waste and abuse.
  • Implement audit directives approved by the Audit & Compliance Committee of the Board of Directors, oversee internal audit operations, and provide leadership and direction in communicating and monitoring audit policies, procedures, practices, programs, and processes.
  • Develop and maintain the Code of Conduct to provide employees with meaningful guidance for compliance and ethical standards.
  • Primary contact for the CMS and other regulatory agencies, responsible for official responses regarding issues, complaints and enforcement actions. Respond to government investigations and queries as the principal point of contact.
  • Provide education and training on the Code of Conduct, compliance, guidance, laws and regulations.
  • Identify risk proactively, direct audits and corrective actions, investigate reported non-compliance and Code of Conduct violations, and ensure non-compliance issues are promptly investigated and resolved.
  • Ensure compliant systems and processes are in place for effective management of Plan functions, including but not limited to: enrollment and billing, sales and marketing, member services, claims processing, grievances and appeals, medical management, quality management, reporting, network management, pharmacy management, contract administration, and other CMS requirements.
  • Manage and minimize risk for conflicts of interest.
  • Conduct mock-audits and train associates.
  • Oversee internal audit controls to ensure departmental compliance to all regulatory standards.
  • Oversee the Special Investigations Unit, including audit, investigation of referrals, and special projects.
  • Ensure competency and management of Compliance staff, including recruitment, selection, training, development, coaching and their representation of the Compliance Department.
  • Collaborate with other departments on compliance risk, issues, audits and corrective actions.
  • Consult with General Counsel/lawyer, as needed, to identify and resolve legal issues and concerns.
  • Perform functions according to established policies and procedures, regulatory requirements and applicable professional standards.
  • Provide customers, internal and external, with professional service and demonstrates core and leadership behaviors.
  • Additional duties, as assigned.

Education and Experience

  • Bachelor degree is required. Master degree is preferred.
  • Ten (10) years’ experience working in Medicare managed care and not less than five (5) years in Medicare Advantage health plan is required.
  • Certification in Healthcare Compliance required.

Knowledge, Skills, and Abilities

  • Analytical and critical thinking skills are required.
  • Expert knowledge of current CMS regulations governing Medicare Advantage and Medicare Part D required.
  • Expert knowledge of HIPAA regulations required.
  • Experienced at interfacing with national and regional CMS offices.
  • Must have a credible background with CMS and CA DMHC.
  • Presentation skills for training large and small groups
  • Excellent communication skills

Physical & Working Environment

Typical Physical Demands.
Position requires a great amount of sitting and standing. Some lifting, stooping, bending, or reaching is required. May require lifting up to 15‐30 pounds. Requires manual dexterity sufficient to operate a computer, calculator and telephone. Requires normal range of hearing and vision. Requires the ability to type and file.

Typical Working Conditions.
Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. Work may be stressful at times. May occasionally work some irregular hours.

Apply for the VP, Audit & Compliance Officer position at Clever Care Health Plan