Sr. Compliance Specialist

Central Coast Salary Range - $95,062 - $137,840

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

The Senior Compliance Specialist is responsible for ensuring that an organization adheres to regulatory and contractual requirements, as well as internal policies and procedures. They assess risks, support development of CenCal Health’s Compliance Program, and provide guidance to management and staff on compliance-related matters. The Senior Compliance Specialist is responsible for ensuring accurate, high quality, and timely submissions of required regulatory reports and submissions to regulatory agencies.

Duties and Responsibilities

• Regulatory Compliance:
   

  • Monitors, reviews, analyzes, interprets, and summarizes new or revised federal and state regulatory requirements applicable to CenCal Health’s Dual Special Needs and Medicaid lines of business.
     

  • Distributes new or revised federal and state regulatory requirements, policy guides, All Plan Letters (APLs), Health Plan Management System (HPMS) memos, and other regulatory guidance to CenCal Health’s management team and is responsible for leading collaborative meetings with business leaders to ensure implementation of new or revised regulatory requirements.
     

  • Ensures as part of implementation of new or revised regulatory requirements, business leaders revise or create policies and procedures that reflect requirements and changes in operations.
     

  • Ensures CenCal Health policies align with state and federal laws, regulations, and guidance applicable to the Dual Special Needs and Medi-Cal line of business.
     

  • Supports maintenance of a summary requirements crosswalk detailing Medicare Advantage, Medicare Part D, and Dual Special Needs Plan requirements in comparison to Medicaid requirements.
     

  • Ensures member communication and marketing materials align with state and federal regulations and guidance, provides guidance to business leaders regarding development of member materials, maintains a tracking log of member materials, and submits applicable member materials to CMS, DHCS, or DMHC for review, as required.
     

  • Supports maintenance of an organizational policy and procedure library.
     

  • Supports maintenance of a resource library including source documents, policy guides, and other regulatory guidance, made available to all CenCal Health employees.
     

  • Participates in communication and relationship building with CMS, DHCS, DMHC, and other applicable regulatory agencies.
     

  • Provides subject matter expertise and guidance for compliance-related inquiries.
     

  • Supports preparation for quarterly Compliance Committee meetings. Provide content for reports and presentations. Presents material to the Compliance Committee, as needed.
     

  • Mentors junior team members and provides training regarding Medicaid, Medicare, Medicare Advantage, Medicare Part D, and Dual Special Needs Plans, fostering a collaborative and growth-oriented team environment.
     

• Regulatory Reporting and Submissions:
   

  • Ensures and is responsible for the preparation of accurate, high quality, and timely submissions of both ad hoc and routine regulatory reports and submissions to regulatory agencies.
     

  • Supports the development of internal processes to facilitate the timely submission of regulatory reports and submissions.
     

  • Coordinates with departmental leadership to prepare documents, reports, and other key deliverables required for regulatory reporting and submissions.
     

  • Ensures all appropriate leadership positions (e.g., director and officer) have appropriately signed off on regulatory reports or submissions prior to submission and approvals are appropriately documented in department tracking tools.
     

  • Ensures records and documentation of submitted reports and submissions are well catalogued and complete.
     

  • Supports the development and maintenance of a regulatory reporting and submissions calendar, including all reports and submissions required.
     

  • Other duties, as assigned.
     

Knowledge / Skills / Abilities

• Understanding of regulatory or compliance processes impacting managed health care, Medicaid and Medicare.
   

• Understanding of basic principles of Medicaid and Medicare to include Medicare Advantage and Medicare Part D.
   

• Understanding of the managed health care model.
   

• Understanding of federal and state regulatory agencies and processes.
   

• Understanding of CenCal Health’s operations and processes a plus.
   

• Ability to facilitate discussions and deploy action requests to large cross functional groups.
   

• Ability to effectively, clearly and independently document, summarize and resolve complex issues.
   

• Demonstrate excellent problem-solving skills and analytical skills with high attention to detail.
   

• Demonstrate success in a collaborative culture, including the ability to navigate different working styles and priorities across teams. 
   

• Demonstrate process improvement experience and a growth mindset.
   

• Ability to effectively prioritize multiple tasks and deadlines.
   

• Ability to analyze and interpret regulatory and contractual requirements.
   

• Ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position.
   

• Ability to handle sensitive information with confidentiality and integrity.
   

• Ability to develop, organize, and navigate electronic and paper filing systems.
   

• Ability to communicate accurately and effectively, both orally and in writing.
   

• Ability to establish and maintain effective and cooperative working relationships with management and staff.
   

• Ability to work under pressure to accurately complete tasks within established deadlines.
   

Education and Experience
 

• Must have at minimum 5 years’ experience in the health care field (preferably in a managed care setting).
   

• Must have at minimum a Bachelor’s Degree in a related field. An additional 4 years’ experience may be accepted in lieu of a Bachelor’s Degree (a Master’s degree is a plus).
   

• Must have experience and knowledge with Medicaid, Medicare Advantage and/or Medicare Part D requirements, reporting, and submissions; and working with federal and state regulatory agencies, including but not limited to, DHCS, DMHC, CMS and/or the Office of Inspector General (OIG).
   

• Must have experience with reviewing, understanding, analyzing, interpreting, and summarizing new laws and regulations or changes in laws and regulations.
   

• Must have experience researching, compiling and organizing information from various source.
   

• Must have knowledge of and proficiency in the use of Microsoft Office Suite, including, Word, Excel, PowerPoint and SharePoint, as well as SmartSheets.
   

• Must have attention to detail and accuracy.
   

• Must have time and/or task management experience, and the ability to prioritize tasks (project management experience is a plus).
   

• Must have experience in the creation, preparation, and presentation of reports and presentations.
   

• Comfortable with learning to use new computer systems as necessary to support Compliance programs.
   

• Healthcare Compliance Certification (preferred).