Health New England

About Health New England

SUMMARY: The Director of Compliance and Accreditation serves as the Medicare Compliance and Privacy Officer of HNE, reporting to the President & CEO and the Board of Directors. The Director has the critical responsibility of certifying HNE’s high level of compliance with all Federal and state laws and regulations, including Medicare, Medicaid company program policies; the HNE Code of Conduct and all relevant state and federal regulatory standards. The Director oversees and directs activities necessary for an effective Corporate Compliance Program, including developing, implementing and enforcing compliance policies; conducting education sessions; determining how legal rules and regulatory matters impact HNE’s business and policies; assisting teams in formulating sound business policies that meet legal requirements as well as business needs; investigating reports of noncompliance; monitoring and reporting results of compliance efforts; and providing guidance for the Board and executive leadership team on matters relating to compliance. ESSENTIAL FUNCTIONS: Leadership: Leads and oversees the fulfillment of all regulatory accreditation activities for Health New England. Leads the development and implementation of policies, procedures, and standards of conduct in compliance with regulatory requirements and state and federal contract requirements. Approves all new policies and relevant amendments to maintain conformity and compliance with new regulatory developments at the state and federal level Serves as Medicare Compliance and Privacy Officer. Chair HNE’s corporate compliance committee. Present reports on compliance activities and concerns. Directs the design and implementation of all monitoring elements of Health New England’s effective compliance program for all lines of commercial and government business, including Medicare and Medicaid. Programs Management: Oversees the internal compliance monitoring and auditing activities as well as the annual risk assessment and compliance work plans design. Leads the development of organizational processes to regularly and consistently review and verify the implementation and status of HNE’s compliance efforts as a part of the overall risk-based compliance business strategy. Directs HNE’s Medicare Compliance program Directs HNE's Privacy Program including developing, overseeing or facilitating company-wide privacy training. Develops (internal and external) effective lines of communication to report suspected non-compliance activities. Partners with key stakeholders to apply compliance standards throughout the organization utilizing different communication channels. With the Director of Human Resources and Organizational Development, ensures the application of disciplinary actions as per Associate’s Handbook certifying the measures are applied fairly and consistently. Responds promptly to detected offenses, independently investigating (or, where appropriate, initiating an independent external investigation) and acting on matters related to compliance, including the flexibility to design and coordinate internal investigations (e.g., responding to reports of problems, 'hot-line' calls, or suspected violations) and developing corrective action plans. Provides regular (monthly, quarterly, annual) reports to the Baystate Audit and Compliance Committee, the Executive Leadership Team and, when necessary, the government at the state/federal level as applicable. Develops and sustains a positive working relationship with government agencies and officials. Accreditation Programs: Oversees the administration of the NCQA Accreditation process for Health New England by managing survey readiness activities, working with key stakeholders to ensure NCQA standards are appropriately assigned to their respective areas, providing education and understanding on the purpose and importance of compliance. Liaises with NCQA standard owners, and oversees the development of corrective action plans based on pre-accreditation evaluations or government audit guides and monitor their implementation. Certifies that HNE’s operational areas, management, Board of Directors, delegated entities, and first-tier, downstream and related entities are trained on compliance and on new contractual or regulatory requirements. Oversees processes assessment methodology to identify, assess, improve, and optimize internal control and risk practices within the accreditation program. Oversees, in collaboration with HNE’s Directors, the design, implementation, monitoring, assessment, and reporting of control processes, documentation and risk activities. MINIMUM REQUIREMENTS: J.D., MBA, or equivalent graduate degree; absent that, relevant experience at a similar organizational level and a minimum of 5 years of relevant experience in an executive corporate or Medicare compliance and accreditation role in a managed care setting, or an equivalent combination of education and experience. Healthcare compliance certification an asset. Expert level of knowledge on health care regulatory compliance requirements, NCQA standards requirements, Medicare and Medicaid laws, regulations, processes and standards Proven, leadership knowledge and skills and an ability to work independently or in a team within a fast paced changing environment Excellent ability to research, analyze and interpret laws, regulations, and accreditation standards and determine how to apply them to business operations Exceptional ability to communicate policies, procedures, un-popular decisions, laws and regulations effectively Strong knowledge and experience in leading teams with a keen ability to prioritize multiple tasks effectively Strong analytical, critical thinking, creative problem solving, and negotiation skills Excellent communication and presentation skills; highly organized with a strong attention to details WORKING CONDITIONS: Occasional travel is required within Health New England's business area SUPERVISORY RESPONSIBILITIES: 1x – Privacy Investigation Analyst- (FTE’s to be further determined) 1x – Compliance Investigations Analysts – (FTE’s to be further determined) 1x – Third Party NCAQ Assessments/Accreditation – (FTE’s to be further determined)

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Company Info

Legal Form: Inc

Company Type: Subsidiary or Business Segment

Company Size: 51 - 250

Revenue: 100 - 500 million (USD)

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