Manages the activities of the Compliance Program for one or more of VNS Health’s lines of business to ensure compliance with all applicable local, state, and federal laws and regulations. This includes the ongoing implementation of the Code of Conduct and other Compliance Program policies and procedures as well as additional duties to support the achievement of the objectives of an effective compliance program. Works under general supervision.

• Manages day to day functions of the Corporate, Provider, and/or Health Plan Compliance Programs.
• Audits and monitors activities in accordance with the Compliance Work plan; prepares summary reports for leadership.
• Conducts investigations of allegations or reports of fraud, waste and abuse and/or privacy violations under the direction of compliance and legal counsel leadership, as appropriate.
• Provides education and training to enterprise staff on compliance related issues.
• Assists in coordinating and responding to regulatory policy changes affecting Health Plan and Provider Services operations.
• Collaborates with leadership in developing, reviewing, and revising compliance policies, procedures and related activities for the enterprise. Ensures that enterprise staff are aware of and in compliance with policies and procedures.
• Collaborates with operations to implement corrective actions and implement controls related to identified compliance concerns; evaluates the efficacy of the controls.
• Collaborates with Regulatory Affairs and other internal departments to manage audits conducted by state and federal regulators across the Health Plans and Provider Services.
• Collaborates with Human Resources and VNS Health leadership to ensure consistency of disciplinary actions related to matters of non-compliance, especially those related to fraud, waste and abuse and privacy violations.
• Reviews data for patterns and/or trends that may indicate workstream or process concerns involving errors or quality related issues. Prepares reports to communicate key patterns and/or trends and their implications from a compliance/risk perspective. Provides recommendations to address the identified concerns and follows-up with any implemented changes.
• Utilizes data to develop process improvement recommendations. Ensures that regulatory changes or other updates are incorporated into process flows and that concerns are resolved across the appropriate process teams.
• Assists with responses to external requests including, but not limited to, government audits and record requests from oversight agencies.
• Communicates with state and federal regulators in seeking guidance, responding to inquiries, and implementing regulatory updates.
• Creates an environment that encourages the reporting of compliance concerns and allegations.
• Keeps up-to-date regarding compliance, privacy, and vendor oversight laws, regulations, and trends for all VNS Health entities and programs. Serves as a resource to staff regarding compliance-related matters and questions.
• Collaborates with the Risk team to conduct an Annual Risk Assessment, and to develop and implement an Annual Compliance Work plan.
• Coordinates the oversight of third-party vendors.
• Works with Delegated Vendor Operations and Quality to manage any external audit responses required by third parties that support the Health Plans and Provider Services.
• Participates in special projects and performs other duties as required.

Education:

• Bachelor’s Degree in Business, Health Care Administration, or related discipline required. Master’s Degree preferred.

Certification:

• Compliance Certification preferred.

Experience:

• Minimum of four years of progressive experience in a health care compliance or auditing environment required.
• Demonstrated knowledge of federal and state health care compliance laws, regulations and requirements required; knowledge and experience with compliance requirements applicable to VNS Health Provider Services, Health Plans, and community benefit programs preferred.
• Strong written and verbal communication, as well as interpersonal and management skills, required.