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This position is responsible for establishing and implementing UCare’s Compliance and Ethics Program; including fraud, waste and abuse (FWA) prevention and detection program, in order to maintain the highest level of ethics and to comply with all relevant federal and state statutes, regulations and other guidance. Oversee Internal Audit Department, Privacy Office, Civil Rights Coordinator, Risk Adjustment Compliance Office, and Special Investigations Unit. CCEO has regular, direct reporting responsibilities to UCare’s President and Chief Executive Officer, the Board of Directors, and the Compliance Committee (a committee of the Board of Directors), as well as ongoing direct access to the same at the CCEO’s discretion.
The CCEO defines the compliance program structure, educational requirements, reporting, and complaint mechanisms, response and correction procedures, and compliance expectations of all UCare staff and first tier, downstream and related entities (FDRs). Direct and coordinate compliance with relevant federal and state laws and regulations, including those impacting Medicare Advantage plans, Medicaid managed care plans, Qualified Health Plans under the Affordable Care Act, health insurer and health maintenance organization (HMO) regulatory matters, and the privacy of member information.
Serve as executive sponsor for the Compliance Committee, which includes responsibility for preparing written materials for Compliance Committee meetings that occur at least once per quarter.
Serve as Chair of the Compliance Oversight Committee, providing company-wide leadership on compliance matters. The Compliance Oversight Committee is a cross-departmental body that promotes an effective and efficient structure for the successful maintenance of UCare’s Compliance and Ethics Program. The committee helps ensure the Program is focused on prevention, surveillance, risk and strength identification, timely reporting, investigation, remediation, and corrective action.
Create, coordinate, by appropriate delegation if desired, educational training programs to ensure that UCare’s Leadership Team, Board of Directors, managers, employees, FDRs, and other pertinent individuals are knowledgeable about UCare’s Compliance and Ethics Program, its Code of Conduct, compliance policies and procedures, and all applicable statutory and regulatory requirements. Serves as a resource to departments’ training programs to ensure they address key compliance requirements.
Report on compliance matters as appropriate to Senior Management and to the Board of Directors. Ensure that compliance reports are provided regularly to the President and Chief Executive Officer, the Compliance Committee, and the Board of Directors. Reports should include the status of UCare’s Compliance and Ethics Program implementation, the identification and resolution of suspected, detected or reported instances of noncompliance, and UCare’s compliance oversight and audit activities.
Develop and implement methods and programs that encourage managers and employees to report violations of the Compliance and Ethics Program and potential FWA without fear of retaliation. Maintain, and strengthen as appropriate, accessible communication for employees to raise compliance issues, including managing reporting mechanisms such as the compliance hotline. Maintain documentation for each report of potential noncompliance or potential FWA received from any source, through any reporting method (e.g., hotline, mail, or in-person).
Oversee UCare’s Risk Adjustment Data Compliance program, including appropriate vendor oversight, and supporting efforts to ensure reporting accuracy. Oversees the facilitation of Risk Adjustment Data Validation audits.
Chairs UCare’s Enterprise Risk Management Committee. Facilitates the process for UCare’s annual risk survey and supports the development of its annual Own Risk and Solvency Assessment report.
Assess company-wide compliance risks and tailor monitoring and oversight to address such risks.
Monitor business operations, with an awareness of daily business activity, to ensure appropriate compliance through compliance reviews, internal controls audits, and coaching of departmental self-monitoring.
Collaborate with the Government Relations Department with respect to state Medicaid agencies, the Centers for Medicare and Medicaid Services, and state Health Insurance Marketplaces as it relates to contract compliance issues and regulatory oversight audits, such as performing pre-audit monitoring and overseeing the implementation of any resulting corrective action plans.
Coordinate investigations with input from the Human Resources Department and the Legal Department in response to detection or reports of potential noncompliance. Collaborate with the Human Resources Department in situations where there is suspected employee fraud or misconduct which may require employee discipline as corrective action.
Oversee the development and monitoring of the implementation of corrective action plans, ensuring implementation of corrective actions in a timely fashion, including corrective actions relating to internal compliance reviews, delegation oversight audits, and regulatory audits.
Oversee UCare’s Privacy Office, which includes responsibilities under the Health Insurance Portability and Accountability Act of 1996 HIPAA, as amended, including regulations promulgated thereunder. Provides oversight, along with the Information Security Officer, of UCare’s Security Program. Serves as a member of UCare’s Privacy and Data Security Committee.
Oversee the development of the Annual Audit Plan.
Collaborate with senior managers throughout UCare to assess the Company’s processes for identifying and managing business risk and delivering organizational effectiveness and efficiency.
Provide periodic reports, as needed, to the Finance and Audit Committee, a committee of the Board of Directors.
Responsible for creating and updating UCare’s Code of Conduct.
Manage the process for annual review, tracking, reporting and archiving of UCare’s policies and procedures. Serves as a resource to business owners regarding compliance requirements in policies and procedures.
Bachelor’s degree is required. One or more of the following certifications/designations is preferred:
Certified Compliance & Ethics Professional, Certified Professional Compliance Officer, Certified in Healthcare Compliance, or Leadership Professional in Ethics and Compliance.
Ten years of progressively more responsible experience in health care compliance or related activities, and a demonstrated ability to work effectively across departments or divisions within an organization.
Experience in HMO or health insurance compliance activities. Experience working with Medicare Advantage plans, Medicaid managed care plans, and Qualified Health Plans under the Affordable Care Act.
At UCare, we deliver high-quality health coverage and services to help members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities.
WORKING AT UCARE
Working at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other. Our values of integrity, community, quality, flexibility, and respect permeate every aspect of our organization – from who we are and how we act, to what we do and how we do it. We owe our continued success to our employees who proudly embody our mission and values in everything they do.
THE UCARE DIFFERENCE
UCare is proud to be a recognized Star Tribune Top Workplace for the 9th consecutive year. As a part of our collaborative team, you'll experience the rewards that come with helping others and seeing the positive results of your hard work. We value and respect each individual's ideas... and contributions, and give you the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, a myriad of volunteer activities, and a number of other rewards. If you're looking for a welcoming environment that celebrates what you have to offer, helps you build on your strengths, and gives you the opportunity to truly make a difference, we invite you to apply.
As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.