COMPLIANCE SPECIALIST

Under the general supervision of the Compliance Officer, the Compliance Specialist assists with the planning, development and implementation of compliance activities which includes performing regular audits, conducting investigations, performing research and implementing DWIHN policies and design control systems to ensure that DWIHN complies with regulatory and ethical standards.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Assists with the planning, development and implementation of compliance activities for DWIHN.
• Performs regular audits and internal reviews.
• Conducts investigations.
• Performs research.
• Implements DWIHN policies and design control systems.
• Educates DWIHN employees about compliance related matters including billing and documentation requirements; vendor relationships; DWIHN member quality and safety; and policies and regulations ofthe Office of Inspector General (OIG)/NCQA.
• Performs investigations of alleged compliance incidents/violations.
• Develops corrective action plans for the resolution of problematic issues.
• Tracks, monitors, and provides reports for all investigation outcomes.
• Researches, audits and/or analyzes complex data.
• Assists with the development, maintenance, and revision of policies, procedures and practices for DWIHN to prevent illegal, unethical, or improper conduct.
• Conducts regular on-going review and analysis of all relevant contractual provisions and state and federal statutes and regulations.
• Develops policies and procedures to conform to relevant state, federal, and/or industry standards and requirements and coordinates efforts with appropriate departmental staff to ensure implementation.
• Researches questions from staff regarding regulatory compliance.
• Responds to external requests for information.

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``` - Provides compliance oversight for DWIHN providers. - Ensures DWIHN's compliance plan meets reporting requirements. - Develops risk management strategies. - Designs control systems to address violations of internal DWIHN policies. - Identifies compliance issues that require remediation. - Files compliance reports with DWIHN for regulatory agencies. - Verifies oversight and monitoring activities. - Consults with legal counsel regarding compliance issues. - Researches emerging compliance issues. - Trains employees on compliance topics. - Assist external auditors with internal and external audits. - Reports to management and the Board of Directors on DWIHN's compliance program. - Determines compliance metrics and establishes a system for tracking these metrics. - Maintains up to date written documentation related to DWIHN policies and procedures. - Creates a compliance resource library for staff members. - Reports compliance violations - Regularly assesses the efficiency of control systems and recommends improvements. - Reviews and evaluates DWIHN's procedures and reports to identify hidden risks or common issues. - Coordinates with DWIHN staff to review all departmental compliance policies. - Performs periodic audits on company procedures and processes. - Leads employee training sessions on legal and compliance issues. - Assists with NCQA certification and compliance. - Assists with Quality Management and Quality Improvement functions. - Performs related duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES (KSA'S)

Knowledge of health care fraud and abuse laws, including the False Claims Act, Stark Laws, and the Anti-Kickback Statute, including the associated penalties.

Knowledge of health care law, regulations and standards.