Texas Health Resources VP Compliance Officer CIN in Arlington, Texas

Southwestern Health Resources (SWHR) was established in April 2016 as a unique partnership between the founding entities, UT Southwestern Medical Center, a public academic medical center, and Texas Health Resources, a private faith-based non-profit health system, based on a shared commitment to create a highly differentiated value proposition in both quality and total cost of care for consumers, purchasers, patients and physicians. A cornerstone of Southwestern Health Resources is a clinically integrated network (CIN) of independent and employed physicians, including the employed faculty physicians of UT Southwestern, the employed physicians of Texas Health Physician Group, and independent community primary care and specialty care physicians.

The Corporate Compliance Officer oversees the Corporate Compliance Program, functioning as an independent and objective body that reviews and evaluates compliance issues/concerns within the organization. The position ensures the Board of Directors, management and employees are in compliance with the rules and regulations of regulatory agencies, that company policies and procedures are being followed, and that behavior in the organization meets the company’s Standards of Conduct. This includes compliance with the requirements of all delegated functions for contracted payors. In addition, the compliance office is responsible for the integrity of all core business reconciliation efforts. The Compliance Officer will ensure the organization submissions and receipts reflect the accurate status of the Company with respect to each payor for the following areas: risk adjustment, 5 Star Quality, claims payment, utilization status, analytics/reporting, and financial/Medicare premium payments. The Compliance Officer will monitor and report on the integrity and accuracy of all reconciliations to ensure the achievement of the Company’s objectives.

The Corporate Compliance Office exists:

  • As a channel of communication to receive and direct compliance issues to appropriate resources for investigation and resolution;

  • As a final internal resource with which concerned parties may communicate after other formal channels and resources have been exhausted;

  • To provide consistency in the compliance program structure across the various subsidiaries; and

  • To assist the business units in assessing internal strengths, weaknesses and helping close gaps to ensure Company objectives are met.

The Corporate Compliance Officer acts as staff to the SEO and Board of Trustees’ Corporate Compliance Committee by monitoring and reporting results of compliance / ethics efforts of the company and in providing guidance for the Board and senior management team on matters relating to compliance. The Corporate Compliance Officer, together with the Corporate Compliance Committee, is authorized to implement all necessary actions to ensure achievement of the objectives of an effective compliance and audit program.

The Vice President Corporate Compliance, CIN has the following duties and responsibilities:

  • Develops initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct. Manages day-to-day operation of the Program.

  • Develops and periodically reviews and updated Standards of Conduct to ensure continuing currency and relevance in providing guidance to management and employees.

  • Assists the business units in developing strategy for the Company to reconcile all capitation payments, premium revenue, internal and external claims payments, clincal/utilization data and member eligibility. Ensures the respective units have processes in place to internally monitor and report payment inaccuracies.

  • Advises and collaborates on the development and revision of policies and procedures for the general operation of the business units and related activities to ensure accurate financial performance by each business unit/department and the payors contracted with Company.

  • Develops and oversees the implementation, development, and maintenance of operational controls, and programs for reconciliation and integrity of the reporting of Company data.

  • Acts as an independent review and evaluation body to ensure that compliance issues / concerns within the organization are being appropriately evaluated, investigated and resolved. Collaborates with other departments (e.g. Risk Management, HR, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the corporate attorney as needed to resolve difficult legal compliance issues.

  • Manages the special investigations unit (SIU) and internal audit teams and responds to alleged violations of rules, regulations, policies, procedures, and Standard of Conduct by evaluating or recommending the initiation of investigative procedures. Develops and oversees a system for uniform handling of such violations.

  • Monitors, and as necessary coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.

  • Identifies potential areas of compliance vulnerability and risk; develops / implements corrective action plans for resolution of problematic issues, and provides general guidance on how to avoid or deal with similar situations in the future.

  • Provides reports on a regular basis, and as directed or requested, to keep the Corporate Compliance Committee of the Board and senior management informed of the operation and progress of compliance efforts.

  • Monitors key performance and risk indicators/metrics to assist with the early identification of risk trends across various operational units.

  • Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline; (b) heightened awareness of Standards of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.

  • Works with Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees as well as ongoing training for all employees and managers.

  • Participates and coordinates the external compliance audits from entities providing oversight including but not limited to, Contracted Payors, State Departments of Insurance, and CMS.

Qualifications

Individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individual with disabilities to perform the essential functions. This role requires the ability to solve problems, think outside-the-box, and be resourceful; must be result-oriented, a quick learner and self-starter. The requirements listed below are representative of the knowledge, skill, and/or ability required to build SWHR's culture for action.

Education and/or Experience:

  • Master’s Degree in healthcare or business related field desired.

  • Minimum 10 yearsmanagement experience in healthcare, compliance or equivalent field required.

  • Familiarity with operational, financial, analytics, quality assurance, audit and human resource procedures and Medicare Advantage regulations is a must.

  • Thorough knowledge of state and federal guidelines, accreditation bodies, participating provider agreements, HIPAA and Third Party Administration (TPA) laws, credentialing regulation and prompt pay laws.

Employment opportunities are only reflective of wholly owned Texas Health Resources entities.

We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.