Manager, Compliance and Risk Management

at  Prominence Health

Responsibilities:
Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.
Learn more at: https://prominence-health.com/
Job Summary: The Manager of Compliance and Risk Management is responsible for managing and improving the Prominence Health Plan Compliance and Risk Management Program to assure compliance with State and Federal regulations for health plan products including Medicare Parts C and D, large- and small-group health plans, third-party administration, and other commercial health plan products. The Manager of Compliance and Risk Management assists the VP, Compliance & Risk Management with oversight of the compliance and regulatory matters and is primarily responsible for overseeing the organization’s operational areas. This position serves as an internal consultant to management and staff regarding compliance with Federal and State laws and regulations (Centers for Medicare and Medicaid, Nevada Division of Insurance, Texas Department of Insurance, Florida Office of Insurance Regulation, and the Florida Agency for Health Care Administration) contract provisions, accreditation standards, and internal policies and procedures. The Manager of Compliance and Risk Management will implement plan-wide initiatives, policies and processes related to the Compliance and Risk Management Program and be responsible for program implementation, risk assessment, incident reporting, reports creation, communications, education and training, auditing and monitoring, and corrective action planning. This position reports directly to the VP, Compliance & Risk Management.

QUALIFICATIONS AND REQUIREMENTS:

• Bachelor’s degree in business administration, healthcare administration, public administration, public health or other related field required; Master’s degree preferred.
• Minimum five years’ experience in health insurance or health care.
• Minimum two years’ demonstrated successful experience and increasing responsibility in compliance, quality improvement, risk management, administrative and/or operational duties in health care, preferably in a management role in a managed care organization.
• Experience with the U.S. DHHS Office of Inspector General compliance program guidelines, State and Federal laws, regulations, policies and practices for the administration of Medicare Advantage, Prescription Drug Plan, and compliance programs in a managed care organization.
• Experience with risk management and quality improvement methodologies to comply with Chapter 641.5, Florida Statutes and Chapter 59A-12.012, Florida Administrative Code, (Internal Risk Management Program), and URAC compliance program, internal controls, quality improvement, and risk management standards.
• Ability to effectively communicate in English, both verbally and in writing.
• Excellent computer skills. MS Word, Excel and PowerPoint proficiency.
• Independent judgment and critical thinking skills required.

Please refer the Job description for details