To develop and implement long-term quantitative analysis strategies to meet NCQA and DHCS standards for reporting. To perform, and assist in the performance of, duties that ensure the accuracy, completeness and truthfulness of enterprise wide regulatory reporting including all data, information and documentation submitted to PHC’s governing agencies. Works collaboratively with all PHC department subject matter experts (SME) to implement new regulatory reporting requirements or templates and assist in troubleshooting regulatory reporting issues. To develop and implement strategies to meet NCQA standards for the oversight of delegate reporting. Supports the plan-wide Privacy and Fraud, Waste and Abuse (FWA) program by preparing trend analysis, forecasting reports and managing data collection in EthicsPoint.

• Responsible for independently validating the accuracy of regulatory reports submitted to the Regulatory Affairs and Compliance (RAC) unit by department SMEs or delegates to ensure reporting is in conformance with the regulatory agencies reporting template and contains the required attributes specified in reporting instructions prior to filing with PHC’s governing agencies.
• Develops and maintains working knowledge of PHC’s governing agencies reporting requirements and NCQA standards for the oversight of delegation reporting to work with key department SMEs to support compliance with all reporting requirements and NCQA standards and assist in troubleshooting regulatory reporting issues.
• Project/program involvement will include working with department SMEs to implement new reporting requirements for new programs and benefits including DHCS Drug Medi-Cal and CCS Whole Child Model.
• Communicate regulatory reporting changes to existing regulatory reporting templates or other reporting requirements to all department SMEs and the Delegation Oversight unit and work with affected departments to implement changes.
• Works closely with department SMEs and Delegation Oversight unit to resolve any regulatory report quality issues.
• Serves as primary contact for internal and external regulatory reporting related inquiries.
• Maintain PHC’s Regulatory Reporting Calendar, Master List Tracking Sheet and Data Certification
• Serves as an active contributor in data quality or analytic workgroups and assist in developing data governance and data quality issue resolution, streamline reporting to reduce unnecessary duplication; ensures consistent and accurate use of regulatory data reporting.
• Under the direction of the Regulatory Affairs Manager, works on analyzing and documenting current processes to determine process needs that will improve the performance and/or increase efficiency within the unit.
• Assist in developing or updating RAC’s processes including policies and procedures, desktop procedures, workflows, best practices and training materials.
• Develop quantitative and trending reports for Privacy and FWA reported incidents via EthicsPoint advanced analytic tools.
• Enhance current tracking and trending mechanisms to consolidate into EthicsPoint.
• Prepare and distribute standard daily, weekly, monthly and quarterly reports and present Privacy and FWA statistic reports to the PTAS and FWA workgroups or Compliance Committee as a backup for the Regulatory Affairs Manager.
• Provide back up and support to Regulatory Affairs Specialist as required in Privacy and FWA investigations, including creating randomized data sampling or other analysis required.
• Research complex regulatory related inquires, provide accurate and timely response utilizing all applicable State and Federal regulations.
• Supports compliance training program.
• Supports internal and external audits
• Participates in special projects and assignments as needed
• Other duties as assigned.

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:

$46.00 - $48.00 / hour

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 or definitive 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.