Oversees the day-to-day operations of Partnership HealthPlan of California’s (PHC) Program Integrity Unit. Responsible for ensuring the timeliness of investigations related to potential or actual HIPAA and fraud, waste, and abuse. Supports training, provides direction to the Regulatory Affairs and Compliance (RAC) staff, and serves as an effective liaison for the organization and its internal and external community. 

• With RAC leadership, supports the management and goal setting for program integrity
  operations 
• Supervises Regulatory Affairs Specialists and ensures staff follow procedures, policies
  and protocols. Defines scope of work, deliverables and timeframes directly with senior
  staff
• Researches complex HIPAA and/or fraud cases to ensure accurate and timely response
  utilizing all applicable State and Federal regulations, available data and documentation,
  and facts of the case. Facilities case conferences with RAC leadership as needed
• Supports PHC’s multi-faceted approach to detect and protect against fraud activity
• Responsible for the completeness and accuracy of the tracking systems and records of all
  reports and investigations related to potential or actual HIPAA and/or fraud
• Participates and represents PHC in meetings and calls with regulators and associations
  and summarizes key points and impact to PHC programs
• Provides HIPAA/FWA training and education to PHC operational departments to promote
  awareness of and adherence with program integrity requirements
• Maintains work plans, dashboards, and other tools intended to provide transparency and
  accurate reporting of program integrity activities and trends
• Responsible for monitoring industry trends and making recommendations for PHC’s
  program to proactively mitigate HIPAA and/or fraud risks and develops and supports
  implementation of interventions

Secondary Duties and Responsibilities

• Participates in special projects and assignments, as needed.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures as they may from time to time be updated.

HIRING RANGE:

$103,059.95 - $133,977.94

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.