Kelsey-Seybold

  • Dir Compliance - KCA

    Location US-TX-Pearland
    Posted Date 6 days ago(11/7/2018 12:53 PM)
    Job ID
    2018-19564
    Category
    Professional/Managerial
  • Overview

    Director of Compliance - KCA

    Location: Pearland Administrative office 

    Department: KS Plan Advantage 
    Job Type: Full Time

     

    COMPANY PROFILE

    Kelsey-Seybold Clinic. Your Doctors for Life.

    Kelsey-Seybold Clinic is Houston’s premier multispecialty group practice, founded in 1949 by Dr. Mavis Kelsey. With 19 clinic locations and more than 400 physicians, Kelsey-Seybold provides medical care in 55 medical specialties and is home to a nationally accredited Breast Diagnostic Center, Endoscopy Center, Infusion Center and Cancer Center. Our mission is to provide our team members with exceptional opportunities for professional and personal growth.

     

    JOB SUMMARY

    The Director of Compliance KelseyCare Advantage is a Medicare subject matter expert who oversees and conducts various compliance-related activities for the Company’s Medicare Advantage (Part C) and Prescription Drug (Part D) health plan programs. Services as a business partner/consultant with health plan operational areas and assists in maintaining an understanding of and compliance with regulatory and legal requirements as well as the organization’s internal policies and procedures. Responsible for monitoring of health plan operational units and downstream delegated entities, assisting/coordinating internal compliance audits and for preparing the organization for audits by external regulatory authorities. This position is responsible for monitoring and managing reports of potential instances of fraud, waste or abuse, including the coordination of internal investigations and the development of appropriate corrective or disciplinary actions, if necessary. This position is responsible for the management and reporting of quality metrics and overseeing data validation, RADV, and HEDIS audits.

     

     

    EDUCATION REQUIREMENTS & EXPERIENCE REQUIREMENTS

     (A = basics; B = preferred)

     

    Education

    A.

    BS in Business Administration, Healthcare Administration or related field.

     

    B.

     MBA or MHA preferred

    Experience

    A.

    7 years of relevant work experience required with at least 2 years directly involved in Medicare Advantage and Part D auditing activities 

     

    B.

     Previous health plan, medical group or hospital experience contracting with providers, TPAs, self-insured employers and/or health plans/payors

     

    Licenses

    A.

    Texas Driver’s license

    B.

     

    Special Skills

    A.

     

    B.

    Certified Internal Audit certification preferred

    Other

    A.

    • Strong verbal and written communication skills
    • Must be proficient with the following programs include Microsoft Word, Excel, PowerPoint
    • Clear speech and diction
    • Fluent in English both verbal and written
    • Demonstrated knowledge of reimbursement methodologies
    • Ability to travel

    B.

     

     

     

     WORKING ENVIRONMENT

    Office 

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