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Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Regulatory Compliance Administrator I who will assist the Manager of Compliance and the Compliance Officer with updating, enhancing and administering all aspects of the Compliance and Integrity Program. The incumbent will provide auditing and review assistance for all aspects of operations and compliance initiatives and will assist in improving the internal control environment at Network Health. The Regulatory Compliance Administrator I will further be responsible for the identification of risk areas and implementation of contract requirements to ensure compliance with applicable laws and regulations. The Regulatory Compliance Administrator I will report findings, recommend improvements and corrective actions. Duties: <ul><li>Assist in developing compliance audit instruments and protocols; revise policies and procedures; design, implement and conduct adequate training under the direction of the Compliance Officer comply with regulatory changes.</li><li>Responsible for the management and retention of key business documents in accordance with document retention guidelines as well as Network Health's record retention policy.</li><li>Assist with implementation of the monitoring and auditing plan for all operational areas; serve as an additional on-site compliance resource for Network Health, consulting with the Compliance Officer where appropriate.</li><li>Maintain Compliance intake forms, respond timely and appropriately to issues raised, and track any corrective actions necessary.</li><li>Assist in evaluating the adequacy and effectiveness of internal controls for compliance with regulatory requirements.</li><li>Assist with developing and implementing tools and procedures for assessing the risk of operations and applicable vendors that perform administrative functions on behalf of Network Health.</li><li>Responsible for reviewing materials intended for members, agents and/or providers to ensure materials meet all requirements outlined by the State and Federal regulations.</li><li>Responsible for facilitating, gathering and submitting data and other documentation from operational areas for external audit and data validation requests.</li><li>Conduct audits of all departments involved in the delivery or administration of Network Health's insurance plans for compliance with State, Federal and Network Health standards</li><li>Perform internal compliance investigations and assess operational risk</li></ul>Requirements: <ul><li>Associate Degree or four years of related experience required; Bachelor's Degree preferred.</li><li>1+ year of compliance or similar regulatory experience required.</li><li>1+ year of experience working with claims processing/monitoring, system configuration, pharmacy, enrollment, finance and/or appeals and grievance related position required.</li></ul>Skills: <ul><li>Strong verbal, written, research and analytical skills</li><li>Exceptional project management and interpersonal skills</li><li>Strong attention to detail</li><li>Must be self-motivated, able to work independently</li><li>Must be able to work effectively with highly interdisciplinary teams</li></ul>We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.

Regulatory Compliance Administrator

Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Compliance Officer to serve as the Chief Compliance and Privacy Officer (CO) for the organization. This critical team member is responsible for the corporate integrity, compliance and privacy programs. The CO is responsible for planning, implementation, design and evaluation of the compliance, privacy programs in accordance with applicable regulations as well as collaborating with Internal Audit to develop and implement a comprehensive risk-based audit plan reflecting a thorough understanding of industry risks and with consideration of all the organization's lines of business. The CO is also accountable for project resourcing, budgeting, planning and execution to set and achieve corporate goals based on strategy, issues, risks and dependencies. This position serves as the organization's Section 1557 Coordinator, retaining ultimate oversight for ensuring Network Health's compliance under Section 1557 of the Affordable Care Act. Duties: <ul><li>Develops, implements, monitors and evaluates the corporate privacy and compliance programs.</li><li>Nurtures and promotes culture of compliance throughout the organization.</li><li>Develops and maintains compliant Business Associate Agreements, to ensure all privacy concerns, requirements, and responsibilities of Network Health's Business Associates are addressed within the agreement, in collaboration with legal counsel, when necessary.</li><li>Oversees and advises organization and Board of Directors on anticipated regulatory changes and potential impacts.</li><li>Establishes, maintains and monitors a system for uniform responses to alleged violations of rules, regulations, policies, procedures, and the Network Health's Code of Conduct and recommends corrective action to senior management and/or Human Resources.</li><li>Oversees compliance with privacy practices and consistent application of the employee sanctions policy for failure to comply with privacy/compliance policies for all employees, extended workforce, and for all business associates, in cooperation with human resources, administration and legal counsel, as applicable.</li><li>Establishes and administers a process for receiving, documenting, tracking, investigating, and taking action on all incidents concerning the organization's compliance and privacy policies and procedures in coordination and collaboration with other similar functions, including ERM, IS Security and legal counsel, as applicable.</li><li>Lead organization efforts for external regulatory audits (including those by CMS and OCI), as well as any required remediation and/or corrective action plans.</li><li>Maintains an effective working relationship with all regulators to ensure the organizations needs are met and to drive company strategy forward.</li><li>Develops and communicates annual compliance work plan and effectiveness assessments and makes periodic reports of progress toward plans.</li><li>Ensures policies, procedures, and practices are designed to promote compliance with the requirements set forth by regulators, including oversight of all FDRs and sanction screening processes and continually refining regulatory support processes and champions review of division processes, workflows, desk level procedures and activities.</li><li>Responsible for development, maintenance and ongoing improvements of general compliance and privacy training and education for the organization.</li><li>Oversees the Network Health Privacy and Compliance Committee, a subcommittee of the Board of Directors.</li><li>Oversees and leads the execution of a risk-based internal audit plan in conjunction with internal audit using department metrics and reports to manage audits and ensures the delivery of relevant, factual, clear and timely reports of audit results to senior leadership and the audit committee.</li><li>Responsible for anticipating and identifying key sources of information to analyze problems clearly, identify root cause of problems, trends, and opportunities and determine creative solutions.</li><li>As Section 1557 Coordinator:<ul><li>Oversees effective implementation of Network Health's language access, effective communication and reasonable modification procedures.</li><li>Receives, reviews and processes grievances related to prohibited actions under Section 1557.</li><li>Coordinates Network Health's recordkeeping requirements under Section 1557</li><li>Coordinates Section 1557 training for employees</li></ul></li></ul>Requirements: <ul><li>Bachelor's degree in Business, Organizational Development or a relation field required.</li><li>Master's Degree in a related field is preferred</li><li>10 years of experience in healthcare, health insurance and/or compliance.</li><li>5+ years' leadership experience including directing teams in planning, launching and managing cross department projects.</li><li>5+ years' experience in leadership development</li><li>Certification in Health Care Compliance (CHC) is required OR must be obtained within 24 months of employment.</li></ul>Skills: <ul><li>Demonstrated strategic skill set: able to synthesize and translate inputs, business performance metrics and strategic directives into projects and action plans.</li><li>Ability to mitigate risks proactively and resolve issues, escalating to the board of directors when appropriate.</li><li>Ability to work through legal contracts to reduce risk and ensure compliance with applicable State and Federal regulations.</li><li>Ability to understand complicated regulatory challenges and supply concise and relevant answers.</li><li>Ability to make informed and researched based strategic and regulatory recommendations with an understanding the impact to the company's resources and bottom-line.</li><li>Detail-oriented with the ability to manage projects from inception through execution.</li><li>Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, government regulations and legal documents.</li></ul>We are a recent Best Places to Work award winner from the Milwaukee Business Journal. To learn more about us and the benefits we offer, please visit <a href="http://www.networkhealth.com/careers" target="_blank">www.networkhealth.com/careers</a>. We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.

2 Jobs in Menasha, WI, USA