• Job Description

  Req#: COMPL025581

  Essential Job Duties

  • Create and maintain databases and spreadsheets related to regulatory submissions and reporting,
    licensing, contracts, policies, procedures, laws and regulations.
  • Assist in the monitoring and auditing for compliance with privacy and security regulations
  • Understand and prioritize timeframes associated with CMS Medicare Advantage (MA) Prescription Drug (PD), federal and state regulatory submissions/reporting calendar, AHP Compliance Toll-Free Hotline, CMS
  • Complaint Tracking Module (CTM) and other documents
  • Communicate state and federal requirements to internal and external clients
  • Review and monitor new and updated laws and regulations, disseminating findings to key stakeholders accordingly.
  • Participate on various compliance subcommittees and workgroups
  • Perform periodic compliance audits, risk assessments and conducts related ongoing compliance monitoring activities as assigned within the quality work plan, compliance work plan and/or internal audit work plan.
  • Assist management with Compliance Committee meetings, agendas and minutes.
  • Participate and attend Compliance Committee and other company committees, subcommittees and workgroups, as assigned.
  • Prepare analyses/reports based on audit results, including recommendations for corrective action; maintain records of audits and follow-up of corrective actions
  • Assist management in developing compliance audit instruments and protocols; assist Management in the development of new and/or revise Medicare Compliance departmental policies and procedures to comply with federal and state regulatory changes
  • Under leadership’s guidance, communicate with regulatory agencies to clarify requirements, address reporting and filing issues
  • Maintain awareness of industry trends and legislative impact on policies, products and services
  • Respond to external requests for information required by the organization for its regulatory filings; respond to inquiries from state and federal regulatory agencies
  • Assist in developing, producing and conducting compliance training programs
  • Assist affiliated and managed health plans in managing relationships with regulatory agencies and seek to resolve policy issues which may negatively impact service to members
  • Other projects and responsibilities as assigned by management

  Required Skills:

  • Encourage an atmosphere of optimism, warmth and interest in patients’ personal and health care needs
  • Excellent verbal, written, and interpersonal communication skills
  • Working knowledge of related federal and state laws and regulations and CMS compliance
  • Ability to demonstrate strong understanding of CMS requirements and regulations related to Medicare
    Advantage and Medicare Part D operations and compliance; has extensive familiarity with relevant
    resources and is available to provide technical assistance and guidance to business units
  • Ability to effectively present highly complex information and respond to questions from groups of
    managers, clients, customers, and the public

  Required Work Experience

  • Minimum (3) three years’ related experience in compliance, privacy and/or regulatory affairs, legal
    assistant/paralegal
  • Experience in health care industry in related field including understanding of regulatory, contractual, and
    operational responsibilities of Medicare Advantage plans and Health Maintenance Organizations
  • Medicare Compliance, medical claims processing/auditing experience, PBM, and/or pharmacy audit
    experience preferred
  • Project management experience and handling multiple high priority projects with competing deadlines
  • Working knowledge of laws and/or regulations in area of compliance; specifically, CMS MA/PD Program,
    HIPAA, FWA, and state department of insurance laws, regulations and administrative rules
  • Strong auditing background preferred
  • Qualifying criminal background

  Licensing/Certification/Education Requirements:

  • Bachelor’s degree required, preferably in business, finance, accounting, legal, or healthcare
  • Certification in Healthcare Compliance (CHC) or other relevant certification(s), or must obtain within the
    first two (2) years of employment

  Equal Opportunity Employer
  This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

• About the company

  American Health Communities (AHC) is a network of skilled nursing and rehabilitation facilities in Tennessee and Northern Alabama.

Notice