ACA Compliance Program Manager - PCHP

Parkland Community Health Plan's (PCHP's) Program Manager, ACA, is responsible for ensuring that PCHP complies with all applicable laws, regulations, and internal policies. Key responsibilities include developing and implementing compliance policies and procedures, conducting regular internal audits, ensuring employee training on compliance, managing relationships with regulatory agencies and leading compliance investigations. The role requires a strong background in health care compliance management, excellent attention to detail, and the ability to effectively communicate and educate team members on compliance requirements. Work schedule: Hybrid / Full-time days, 8 a.m. until 4 p.m., Monday through Friday.

Responsibilities

Maintain and track applicable federal and state laws, regulations, and sub regulatory guidance affecting the ACA product line; Provide compliance oversight of sales, marketing, agent/broker activities, quality, provider and network management, clinical operations, utilization management, claims, premium billing, enrollment and eligibility, and member services; Manage and support the annual QHP certification, recertification, and renewal cycle, including CMS plan and benefit data submissions and TDI form and rate filings; Coordinate and monitor federal and state regulatory reporting and data submissions for the ACA product line, including MLR reporting, risk adjustment, and transparency in coverage reporting; Develop policies, procedures, and an annual review process to ensure compliance; Provide guidance to departments on implementing new and changing ACA requirements; Conduct compliance audits and monitoring of ACA operations and delegated entities; develop and implement corrective action plans; support CMS, HHS-RADV and TDI audits and examinations; Perform risk assessments and report emerging trends, deficiencies and variances; Review member-facing materials and marketing content for compliance; Monitor complaint, appeal, and IRO processes for compliance with federal and state requirements; Support oversight of delegated vendors and related entities performing ACA functions; Provide required ACA/Marketplace-specific compliance training; Provide mentoring and guidance within the department; Lead compliance investigations and manage relationships with regulatory agencies

Requirements

Bachelor's degree in business, public health, health policy, health care administration, legal studies or a related field; 5+ years of directly related experience in managed care operations, health care compliance, and related legislative and regulatory research (or an equivalent combination of education and related experience); Experience in the administration, management and oversight of ACA products and plans, with a focus on contract compliance, audits, corrective action plans and risk management; Experience developing, implementing or administering compliance education and training specific to the ACA; Experience and demonstrated knowledge of relevant federal and state government regulations, guidelines and reporting requirements for CMS and TDI regarding the administration and oversight of ACA products and plans; Strong analytical, critical thinking and problem-solving skills with meticulous attention to detail; Strong communication skills demonstrating effective, professional interaction with federal and state regulatory agencies in a managed care or insurance environment; Ability to collaborate cross functionally with diverse stakeholders; Ability to lead and work independently, and as part of a team; Skilled at developing and implementing corrective action plans; Ability to manage multiple deadlines and time constraints; High proficiency in Microsoft Word, Excel, and PowerPoint

Nice to have

Strong candidates have experience with Affordable Care Act (ACA) regulations, compliance requirements, reporting, or administration; Master's degree in business, public health, health policy, health care administration, legal studies and/or another advanced degree in a related field; Certified in Healthcare Compliance (CHC) from HCCA; Certified Compliance and Ethics Professional (CCEP) from SCCE; Certified Professional Compliance Officer (CPCO) from AAPC; Strong legal/regulatory knowledge, risk management, policy development, investigative skills, and/or experience detecting fraud, waste and abuse