Job Description

Job Title: Administrator, CHC Compliance
Job ID: 590773
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day
Facility:
Department: Community HealthChoices
Location: 600 Grant St, Pittsburgh PA 15219

Description

The Administrator, Community HealthChoices (CHC) Compliance reports to the Sr. Director, Medicaid & MLTSS Compliance. This position strategically ensures compliance with all relevant and applicable Medicaid and MLTSS laws, regulations, contractual agreements, standards and requirements in a manner that continually supports the business and operational areas.

Responsibilities:
  • Assists in the development of clear, effective and timely reports and updates for senior management and/or the Board regarding Medicaid and MLTSS Compliance Program effectiveness, initiatives and issues, including all relevant metrics, dashboards and information.
  • Develops, assesses and adapts clear and effective Medicaid and MLTSS Compliance policies, procedures, training, communications and awareness materials, campaigns, controls and initiatives to ensure clear and consistent understanding and practices throughout internal and external operations to ensure proper and timely preventive measures.
  • Develops, assesses and adapts clear and effective remediation and corrective action initiatives, protocols and controls to ensure proper and timely compliance.
  • Develops, assesses, and adapts clear and effective Medicaid and MLTSS Compliance monitoring, testing, reporting, auditing and sampling protocols, controls and channels to ensure the proper and timely detection of relevant issues.
  • Ensures compliance with required Medicaid and MLTSS laws, regulations, contractual requirements, standards and practices for all relevant stakeholders, both internal and external to the organization.
  • Ensures strategic and operational partnership and collaboration with the business and operational areas, as well as with sibling Governance, Risk & Compliance (GRC) teams to leverage cross-departmental synergies and efficiencies.
  • Keeps abreast of changing industry requirements and regulations, including all relevant laws, rules, contractual agreements, industry standards, company practices and initiatives. Provides clear and effective reports to the relevant business, functional and operational areas, as well as other internal/external stakeholders, regarding new or prospective Medicaid and MLTSS laws, regulations, contractual requirements, industry standards and best practices.
  • Performs other duties as assigned. Effectively lives, models, communicates and supports the values of UPMC and UPMC Health Plan. Performs in accordance with UPMC System-wide competencies and behaviors.
  • Represents UPMC Insurance Services Division in all third party- and customer-originating or facing Medicaid or MLTSS Compliance-related reviews, investigations or requests for information.
  • Represents UPMC Insurance Services Division with all relevant regulatory agencies and entities regarding Medicaid and MLTSS Compliance reviews, investigations or requests for information.
  • Works with Sr. Director to complete regular gap analyses, risk assessments and program effectiveness assessments for Medicaid and MLTSS Compliance Programs.
  • Works with Sr. Director to conduct annual and ongoing Medicaid and MLTSS Compliance training to UPMC Insurance Services Division staff and applicable parties.

Qualifications

  • Bachelors degree required.
  • Relevant graduate degree (e.g. Juris Doctor or Masters degree in a related field) preferred.
  • Minimum of 5 years of Medicaid and/or LTSS legal and/or compliance experience required, preferably on the insurance (payer) side.
  • Prior in-house legal or compliance experience strongly preferred.
  • Pennsylvania-specific Medicaid and/or LTSS experience preferred, but not required.
  • Successful experience in designing and building highly effective relevant compliance programs from scratch and/or significantly enhancing such programs strongly preferred.
  • Strong subject matter expertise and knowledge of all relevant Medicaid and LTSS laws, regulations, contractual requirements, industry standards and best practices required.
  • Strong acumen and understanding of healthcare, health insurance and managed health care industries and organizations required.
  • Excellent oral, listening and written communication skills. Strong project management skills and experience required, particularly as it relates to managing and leading across large and matrixed organizations.
  • Must have strong analytical and organizational skills as well as problem-solving capabilities to ensure that business plans and strategies do not subject the organization to legal, regulatory or contractual violations and/or undue risk or exposure.
  • Strong partnership-, relationship-, consensus- and coalition-building skills required. Strong emotional intelligence and self-awareness required. Strong executive polish and presence required.
  • The role requires a leader who strikes the optimal balance between strategically navigating the compliance requirements and business needs in a manner that's nuanced and mutually reinforcing.
  • Strong strategic, business, operational and leadership mindset and skills required. Highly consultative and partnership-oriented in approach.
  • Strong and reliable judgment and discretion required. Strong ability to independently and self-sufficiently identify, navigate and successfully resolve various Medicaid- and MLTSS-related issues.
  • Strong ethical compass and integrity capital required.

Licensure, Certifications, and Clearances:

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $29.99 to $51.22

Union Position: No

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