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Dir, Risk Adjustment Compliance

Primary Location Oakland, California Job Number 1081178 Date posted 06/15/2022
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Job Summary:

The primary purpose the Director, Risk Adjustment Compliance is to provide oversight and maintenance of a high-quality, effective, best practices risk adjustment compliance program to prevent and detect violations of law and other misconduct and to promote ethical practices and a commitment to compliance with applicable federal, state, and local laws, rules, regulations, and internal policies and procedures. This position plays a key role in providing direction for the risk adjustment compliance function as well as maintaining enterprise-wide view of risk adjustment compliance activities. Risk Adjustment includes the following: Medicare Advantage, Affordable Care Act (ACA) and Medicaid.

Core Responsibilities

In addition to the key responsibilities listed below, the position serves as a compliance subject matter expert related to risk adjustment, including risk adjustment coding, oversees internal and external audit (RADV) activities related to risk adjustment, monitors compliance with national risk adjustment policies and procedures, provides support for teams to stay abreast of the latest coding/billing developments impacting risk adjustment, and monitors the accuracy and quality of coding/billing assignments impacting risk adjustment. Additionally, this position is responsible for developing the annual risk adjustment compliance work plan in alignment with business objectives, reviews audit results, sets the direction for risk adjustment compliance reviews and focused projects related to audit outcomes, and enforces compliance and the Principles of Responsibility (KP's code of conduct).

The Director, Risk Adjustment Compliance demonstrates continuous learning and maintains a highly skilled and engaged workforce by aligning resource plans with business objectives; oversees the recruitment, selection, and development of talent; motivates teams; prepares individuals for growth opportunities and advancement; stays current with industry trends, benchmarks, and best practices; provides guidance when difficult decisions need to be made; and adheres to performance management guidelines and expectations drive business needs.

Essential Responsibilities:

  • Demonstrates continuous learning and maintains a highly skilled and engaged workforce by aligning resource plans with business objectives; overseeing the recruitment, selection, and development of talent; motivating teams; preparing individuals for growth opportunities and advancement; staying current with industry trends, benchmarks, and best practices; providing guidance when difficult decisions need to be made; and ensuring performance management guidelines and expectations drive business needs.

  • Oversees the operation of multiple units and/or departments by identifying customer and operational needs; analyzing resources, costs, and forecasts and incorporating them into business plans; gaining cross-functional support for business plans and priorities; translating business strategy into actionable business requirements; obtaining and distributing resources; setting standards and measuring progress; removing obstacles that impact performance; guiding performance and developing contingency plans accordingly; and ensuring products and/or services meet customer requirements and expectations while aligning with organizational strategies.

  • Oversees company compliance activities by ensuring team members, including external business partners, provide support to internal and external stakeholders; reviewing and approving compliance activities; designing strategies for the implementation of regulations and regulatory changes; ensuring compliance activities are fully documented; and overseeing the resolution of compliance issues.

  • Directs compliance reporting efforts across multiple business functions by overseeing the evaluation and summary of compliance data, audit information, and potential risks and remedies; identifying and reporting key compliance drivers, liabilities, and performance indicators (for example, adherence to standards, incorporation of new regulations) to senior management; and developing complex presentations to convey key findings to executive leadership and external business stakeholders.

  • Directs compliance investigations across multiple business functions by overseeing the collection and analysis of quantitative and qualitative data; conducting interviews on escalated issues as appropriate; reviewing and evaluating research on key business issues; and evaluating and recommending corrective action plans for substantiated allegations.

  • Directs programs or compliance components of larger cross-functional programs by identifying and managing stakeholder contacts; assembling teams based on program needs and team member strengths; developing, analyzing, and managing program plans; negotiating and managing program schedules and resource forecasts; and managing program financials and deliverables.

  • Directs activities associated with continued regulatory compliance for multiple business functions by monitoring, interpreting, and designing strategy around regulatory changes; determining the impact of changes to the business; providing direction on implementation of changes throughout the business; and providing regulatory input before and during inspections to minimize the risks of future non-compliance.

  • Directs and oversees the implementation of compliance efforts by approving compliance requirements; ensuring the assessment of current state compliance to identify gaps and corrective actions; overseeing the analysis and development of complex compliance standards, policies and procedures, and training; and ensuring the monitoring of ongoing compliance adherence.

Minimum Qualifications:

  • Minimum four (4) years experience in a leadership role with or without direct reports.

  • Bachelors degree in Health Care Administration, Clinical, Law, Public Health, Business or related field and Minimum ten (10) years experience in health care compliance, health care operations (quality, risk, etc.), audit, finance, regulatory or public policy development, investigations, information security, or insurance/health plan governance or a directly related field. Additional equivalent work experience in a directly related field may be substituted for the degree requirement.

  • N/A

Preferred Qualifications:

  • Five (5) years experience in health plan compliance.

  • Five (5) years experience in health plan operations.

  • Five (5) years experience working on fraud or white collar investigations.

  • Five (5) years experience working cross-functionally across departments, functions, or business lines.

  • Two (2) years program management experience.

  • Five (5) years health care experience.

  • Three (3) years supervisory experience.

  • Two (2) years experience managing operational or project budgets.

  • Masters degree in Health Care Administration, Clinical, Law, Public Health, Business or related field.

  • JD degree.

  • AAPC or AHIMA certification preferred.

  • Certified in Healthcare Compliance (CHC) or other equivalent compliance certification.

Primary Location: California,Oakland,Ordway Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 08:00 AM Working Hours End: 05:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: NUE-PO-01|NUE|Non Union Employee Job Level: Director/Senior Director Specialty: Compliance General Department: Po/Ho Corp - Compl Govt Audit and Reimburse - 0308 Travel: No Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.