Regulatory Affairs Specialist

Overview

Under supervision of the Regulatory Affairs and Compliance (RAC) leadership, this supports the plan-wide HIPAA program and Fraud, Waste, and Abuse (FWA) program and acts as a liaison between the plan and our regulatory agencies. This position coordinates daily efforts between departments to conduct investigations into potential privacy or FWA related incidents, assess and mitigate risk as well as develop corrective action plans when applicable.

This position supports the plan’s compliance program and assists in efforts to be compliant with applicable laws, regulations, and policies.

Independently investigates privacy and fraud, waste, and abuse referrals ensuring compliance with contractual, regulatory, and statutory requirements and timelines. Interfaces with internal and external stakeholders through investigations and fact gathering and as necessary, makes recommendations to RAC leadership for the escalation of investigations. Develops and delivers education to internal and external stakeholders to promote awareness and understanding of privacy and FWA rules to mitigate risks.

Maintains investigative system of record and is directly responsible for timely submission of all regulatory reporting requirements. Using the appropriate DHCS reporting form, drafts initial reports, updated reports and final reports and submits timely to the designated DHCS reporting unit. Responsible for identifying trends and linking related cases to assist with trending patterns and maintaining accurate data for daily, monthly, quarterly, and annual privacy and FWA analytics.

Works directly with DHCS Privacy Officer to report privacy related incidents, provide updates upon request, ensure timely filing requirements are met for all reports and follows up on pending cases to confirm cases are closed with the DHCS Privacy Office. Works directly with DHCS Program Integrity Unit (PIU) and DHCS Audit & Investigation Unit (A&I) to report potential FWA related cases, provides case updates as new evidence is found, ensures timely filing requirements are met for all reported cases and follows up on pending cases to confirm cases are closed with DHCS PIU or A&I.

Distributes, collects and retains copies of completed compliance primers. Responsible for managing the RAC Inbox and RAC Reporting Inboxes, including:

• Researching regulatory related inquiries and providing responses to inquiries
• Coordinating plan responses to DHCS adhoc requests, surveys or questionnaires
• Supporting submission of regulatory required materials and maintaining a submission tracking mechanism

Secondary Duties and Responsibilities Assists Regulatory Reporting Analyst in the collection of data and other input for recurring reports due to federal, state and other entities requirements. Assists in compiling information into required format and performs quality check for accuracy. Assists Regulatory Affairs and Compliance unit with the administrative functions to support unit meetings, work groups, committees and/or projects. Other duties as assigned.

Education and Experience

Bachelor’s degree in relevant field preferred, two – three (2-3) years of experience in the health care field, managed care experience preferred, with knowledge of the Knox-Keene, Medicare, Medi-Cal, and Healthy Families regulations; or an equivalent combination of education and experience.

Special Skills,

Licenses and

Certifications

Highly proficient in applicable business software applications including PC usage, Microsoft Word, PowerPoint, Excel, Project, typing speed of 30 wpm. Bilingual skills in a Partnership threshold language may be preferred. Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

Performance

Based

Competencies

Excellent oral and written communication skills. Excellent organizational skills with ability to prioritize assignments, maintain effective filing systems, and meet deadlines. Ability to work under minimal supervision and exercise independent judgment. Diplomacy and tact in handling sensitive information…