Director, Regulatory Affairs

Position Summary/Position

At the direction of the VP/Chief Compliance Officer, oversees the health plan’s State and Federal Compliance/Regulatory Affairs program. Ensures compliance with State and Federal laws, rules, regulations, manuals and transmittals pertaining to the Medi-Cal and Medicare Advantage programs by working with various departments to determine the implementation and operational impact of such laws, rules and regulations on the organization and monitor those laws, rules, regulations, manuals and transmittals with which the organization must comply. May act as the Compliance Officer in the absence of the VP/Chief Compliance Officer.  

Major Functions (Duties and Responsibilities)

1. Oversees Medi-Cal and Medicare Regulatory Affairs unit managers and teams by providing leadership, assistance, training, feedback, and motivation necessary to mentor and develop staff.
2. Plans, designs, and implements a comprehensive and dynamic Medi-Cal and Medicare Compliance Program.
3. Collaborates with internal and external department staff and business partners to ensure that processes are in place to identify new laws, regulations, sub-regulatory guidance, and contractual requirements applicable to Medi-Cal and Medicare; distribute new requirements to areas impacted; assist in defining appropriate action; and monitor implementation.
4. Develops, tracks, and monitors compliance performance metrics and prepares performance and compliance reports to leadership.
5. Responds to compliance findings or issues from State and Federal regulators and government agencies, ensuring corrective actions are implemented.
6. Works with other departments to ensure accurate data is submitted timely to State and Federal regulators in compliance with contractual reporting requirements.
7. Performs with broad discretion and independence the preparation and review of all regulatory filings related to the health plan's Knox-Keene and Medicare licenses (ex. contracts, benefits, delivery systems, new products), and partners with key operations leaders to ensure alignment of health plan operations, care delivery, policies, State and Federal regulatory requirements, and Medi-Cal and Medicare administrative health plan functions, including but not limited to DHCS DMHC All Plan Letter implementation, CMS HPMS memos, audits, and contract administration.
8. Serves as a key point of contact for State and Federal regulatory agencies interfacing with the health plan regarding compliance issues, regulatory inquiries and  audits and corrective actions.
9. Develops, coordinates and conducts Medi-Cal and Medicare-specific training programs for the organization’s employees and first tier, downstream and related vendors.
10. Reviews, communicates and monitors all new legislation, regulations and changes in State and Federal laws to ensure the implementation of regulatory requirements at the operational level and to maintain organizational compliance. 
11. Conducts independent investigations on issues of non-compliance and report out findings and mitigation strategy to the CEO, Executive Team and/or IEHP Governing Board as deemed appropriate by the VP/Chief Compliance Officer.

Supervisory Responsibilities

Experience Qualifications

A minimum of ten (10) years of experience in Healthcare, with at least five (5) years in a progressive leadership role in Compliance and/or Regulatory Affairs within a managed care setting. Must have demonstrated knowledge of Medicare and/or Medicaid regulations and experience with applying those regulations into a compliance framework.

Education Qualifications

Bachelor’s degree in a related field from an accredited institution required.

Preferred Education

Master’s degree from an accredited institution preferred.
Juris Doctorate from an accredited institution preferred.
Clinical Degree from an accredited institution preferred.

Professional Certification

Certified in Healthcare Compliance (CHC) preferred. 

Drivers License Required

Skills Requirement

Strong analytical skills with emphasis on time management, financial analysis, project management and problem solving. Exhibits exemplary oral and written communication skills. This includes the ability to share information in an organized, clear and timely manner, both verbally and in writing, keeping peers, colleagues, staff, board members and committee members appropriately informed. Keeps multiple audiences informed, including the ability to exercise discretion in communications with varied stakeholders, to ensure that information is provided appropriately and confidentially, as warranted.

Commitment to Team Culture

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

Word processing involving computer keyboard and screens, automobile travel within the Inland Empire. 

Physical Requirements