Program Manager, Compliance Operations

The eBusiness group at John Muir Health is a dynamic, well-organized team that is passionate about creating innovative web and mobile products that will revolutionize healthcare delivery. In just the past three years, we’ve created a new team, launched a patient portal, a mobile app, a physician portal, and are building innovative applications while fully committed to Agile philosophies that will raise the bar on how healthcare is delivered.

The JMPN Compliance Operations Manager is responsible for managing/coordinating network-wide compliance with federal, state and local health care industry laws applicable to John Muir Physician Network (JMPN), including CMS, OIG, DMHC, CDI and HHS requirements pertaining to programs such as Medicare Advantage, Medicare ACO, HIPAA, Fraud, Waste & Abuse detection, and Knox-Keene regulations. The JMPN Compliance Operations Manager serves as the resource for all staff within JMPN regarding compliance and regulatory questions and is the main point of contact to receive and direct compliance issues to appropriate resources for resolution.

* Administer and manage JMPN compliance program in accordance with JMH corporate compliance program guidelines and requirements. Develop and maintain JMPN compliance standards and procedures and consult with other departments to draft and implement department level standards and procedures that relate to compliance. * Manage compliance program at JMPN to ensure compliance with all * federal, state and local laws and regulations. Act as subject matter expert for day- to-day compliance needs, necessary for appropriate level of decision making to manage compliance program operations. * Manage and maintain JMPN compliance program effectiveness/activity metrics. Provide quarterly entity reports to JMH Chief Compliance Officer. * Develop and provide education programs addressing compliance to employees and physicians, as appropriate. * Participate in the JMH annual corporate compliance work planning process and facilitate/coordinate efforts related to JMPN identified audits and projects. * When audit requests are received at JMH corporate from MACs, Medi- Cal, CMS and OIG, serve as the main contact for JMPN related requests andcoordinate information requested within government mandated deadlines. * Periodically revise JMPN compliance program to address changes in law/regulation, policies and procedures of government and private payer health plans and the needs of JMPN. * When new laws/regulations are passed, provide analysis of such laws/regulations to JMPN leadership to ensure compliance with such laws/regulations. * Facilitate/coordinate JMPN’s compliance contract processes with Legal, Compliance and Privacy, including: HIPAA agreement process to ensure that appropriate HIPAA agreements are put in place with all necessary parties, including health plans, subcontractors/vendors, physicians, and others. * Facilitate JMPN’s HIPAA privacy program in accordance with JMH Privacy Office program requirements to ensure compliance with all laws/regulations, including HIPAA and state privacy laws (e.g., the California Confidentiality of Medical Information Act (CMIA)) laws, and to work with other departments to ensure timely and appropriate investigations and corrective action related to breaches of these laws/regulations. **Risk Operations** * Facilitate JMH compliance and fraud, waste and abuse (FWA) training to JMPN employees and to contracted and employed physician practices and ancillary providers. * Participate and support the development of new products and programs such as ACO implementation and ensure implementation of compliance requirements. * Audit and monitor processes related to delegated claims processing. * Represent JMPN on various Industry Collaboration Effort (ICE) workgroups that pertain to compliance, including but not limited to Contracting & Compliance, HIPAA, and Claims Standardization team activities. * Establish working relationships with federal and state regulatory agencies, including but not limited to the Centers for Medicare and Medicaid Services (CMS), the Office of the Inspector General (OIG), the California Department of Managed Health Care (DMHC), the California Department of Insurance (CDI), and the California Department of Health Care Services (DHCS), as applicable and in coordination with the JMH compliance department. Monitor federal and state statutory and regulatory requirements on an on-going basis, in order to educate appropriate JMPN departments. * Establish and maintain process to monitor JMPN’s status with health plan/payer and program audits and corrective action plans. * Consult with JMPN Contracting to ensure that health plan/payer and physician/ancillary contracts include appropriate language related to compliance. Additionally, communicate to Contracting the impact of legislative/regulatory requirements on existing contractual arrangements. * Maintain and amend/modify applications/licenses and filings with all applicable regulatory bodies, including CMS and DMHC. **John Muir Medical Group Staff Model Compliance** * Act as subject matter expert on health care laws/regulations as a compliance resource to the company and its constituents, including contracted and employed physician practices, including John Muir Medical Group (JMMG). * Develop and maintain professional relationships with federal and state regulatory agencies, including but not limited to the California Department of Public Health (CDPH). Monitor federal and state statutory and regulatory requirements on an on-going basis (working with the JMH Quality Management department), in order to educate appropriate JMPN departments. * Professional Practice Compliance Requirements: Ensure JMMG compliance with professional practice **requirements, including but not limited to requirements related to:** * Patient Informed Consent * Patient Privacy * Medical Waste * Billing Rules and Fraud, Waste and Abuse (FWA) requirements (federal and state, including private payer requirements) * Controlled Substances (Federal and California rules) * Mandatory Reporting (to the Medical Board of California and other state agencies) * Language AssistanceTimely Access to Non-Emergent Health Care Services (including DMHC and CDI rules) * Medical Recordkeeping * Medicare Revalidation * Notification of Financial Interests * Practice scopes for medical staff, including mid-levels and nurses * Self-Referral Rules (federal (“Stark”) and California) * Pharmaceutical Sales Rules * Vaccine Information Statements * Self-regulations/requirements (federal and state, public and private payer requirements)

* Bachelor’s degree. * CHC Certification preferred. * Prefer at least five (5) years of experience in increasingly responsible positions in a complex healthcare organization including experience in compliance and privacy, billing and coding regulations, policies and processes. * Knowledge in Medicare, Medicaid, DMHC, private payer requirements and HIPAA. * Excellent written and verbal communication skills. Ability to express complex issues and situations in clear and understandable terms. The ability to understand and carry out oral and written instructions and to request clarification when needed. * Understanding of revenue cycle and reimbursement for federally funded programs. * Experience in Medicare reimbursement coding, ICD and CPT procedure coding. * Ability to interpret regulatory and legal information and discuss relevancy with leadership; to create and deliver presentations to staff, management, and regulators; and to write, maintain current, and implement policies and procedures. * Ability to motivate, develop and direct people to accomplish objectives. * Acts with confidence, builds credibility and trust. * Uses sound judgment making decisions in the best interest of the organization to drive results given direction in the form of assigned goals and objectives. * Expertise in data gathering, management, reporting and interpretation.