PacificSource Health Plans

  • Senior Compliance Specialist

    Job Location US-OR-Portland
    Job ID
    Regular Full-Time
    Hiring Pay Range
    # of Openings
  • Overview

    Position Overview: 


    The Senior Compliance Specialist is responsible for supporting the Corporate Compliance Officer in administering the organization’s Commercial Compliance Program.  This position is responsible for implementing Compliance Program strategies and initiatives at the direction of the Corporate Compliance Manager. As a senior team member, this position is expected to provide leadership to the team under the direction of the Corporate Compliance Manager.


    Essential Responsibilities:

    • Lead investigations and oversee investigation team’s work on compliance and fraud, waste and abuse (FWA) matters.
    • Lead in the investigation and response to consumer complaints, surveys, inquiries, data calls, market analysis, or examinations received from a state or federal agency.
    • Chair, or assist in chairing, the SIU/Fraud Workgroup.
    • Serve as one of the leads in working with Federal and State law enforcement agencies on all matters pertaining to noncompliance and FWA reporting, such as the NBI MEDIC, CMS, US Department of Justice, OIG, DMAP, and the Medicaid Fraud Control Units.
    • Chair the Compliance Committee and report to the Audit Committee and Board of Directors in the Compliance Manager’s absence.
    • Represent the Compliance Department in monthly CMS Regional Office meetings and internal managers meetings in the Compliance Manager’s absence.
    • Assist in developing the annual Compliance Workplan, which includes conducting a risk assessment and assessing the overall risk to the organization.
    • Assist in identifying and resolving compliance issues related to the organization’s commercial (self-insured and fully insured individual, small group and large group) lines of business.
    • Provides interpretation of rules and regulatory guidance for commercial lines of business
    • Maintain current knowledge of changes in industry rules and regulations and assist in maintaining effective lines of communication with other departments to ensure these changes are disbursed appropriately.
    • Assists in the development, initiation, maintenance and updating of policies and procedures for the general operation of the Compliance Program. Assists with implementation of day-to-day operation of the Program.
    • Identifies potential areas of vulnerability and risk, develops and oversees improvement plans for problematic issues, and provides general guidance on how to avoid or deal with similar situations in the future.
    • Assists with the development and implementation of an effective compliance training program, including appropriate introductory training for new employees and ongoing training for all employees, managers and the Board of Directors.
    • Collaborates with other departments to direct compliance issues through appropriate channels for investigation and resolution.
    • Development of monthly, quarterly and annual reports related to the organization’s commercial lines of business to regulatory agencies as required.
    • Act as a liaison with external auditors and state regulatory agencies as needed.
    • Assists Corporate Compliance Manager in responding to alleged violations of rules, regulations, policies, procedures and Code of Conduct and Ethical Standards.
    • Acts as an independent review and evaluation body to ensure that compliance issues and concerns related to the organization’s commercial lines of business are being appropriately evaluated, investigated, and resolved.
    • Monitors, and as necessary, coordinates compliance activities of other departments in order to remain aware of the status of all compliance activities related to the organization’s business and to identify trends.
    • Participates in maintaining an effective compliance communication program relating to the organization’s commercial lines of business, including promoting:
      • Use of the fraud and abuse hotline;
      • Heightened awareness of Code of Conduct and Ethical Standards;
      • Understanding of new and existing compliance issues and related policies and procedures.
    • Partners with the internal audit function of the organization to ensure effective audit and monitoring as it relates to the Compliance Program.
    • Participates in oversight of delegated entities as determined by the Corporate Compliance Manager
    • Participates in Commercial Programs initiatives as needed
    • Performs day to day tasks of the compliance department as needed
    • Responsible to organize and present state regulations by internal department when company enters a state or new commercial line of business.



    Provide support to the Corporate Compliance Manager and leadership to team under the direction of the Corporate Compliance Manager. Continuous contact with team members, and frequent contact with internal departments and personnel. Request and exchange information in a pleasant, professional manner.  Work with internal departments and personnel to facilitate excellent services for PacificSource customers. Take a proactive approach to ensure quality service.  Participate in regularly scheduled or ad hoc state regulatory agencies (including marketplace) stakeholder meetings regarding compliance issues.


    Work Experience: Minimum 4-6 years experience in the healthcare or health insurance industry with specific experience in commercial compliance.


    Language skills:  Excellent written and verbal communication skills. Ability to clearly communicate with co-workers.


    Mathematical Skills: Basic math skills required, including percentages, ratios, graphing and spreadsheet skills.


    Reasoning Ability: Strong research, analysis, organizational, and interpretative skills. Requires ability to define and prioritize problems and manage workload without direct supervision.


    Education, Certificates, Licenses, Registration: Bachelor’s degree in Business, Health Care Administration, Finance, Accounting or a related field. Masters Degree preferred.


    Other Skills and Abilities: Ability to gain a thorough understanding of PacificSource Commercial Programs initiatives. Extensive knowledge of state (specifically Idaho, Montana, Oregon and Washington) laws and regulations affecting our business. Respond timely to regulatory inquiries. Maintain a working liaison with state regulatory agencies and CMS. Keep Commercial Programs informed of new regulatory developments. Maintain sufficient reference materials to adequately research legal issues. Participate as needed in the annual Qualified Health Issuer application process. Working knowledge of medical terminology. Ability to read and understand health contract and benefits language. Ability to work under time pressures, and to deal with emotional situations.



    Our Values

    • Adaptability
    • Building Customer Loyalty
    • Building Strategic Work Relationships
    • Building Trust
    • Continuous Improvement
    • Contributing to Team Success
    • Planning and Organizing
    • Work Standards
    • We are committed to doing the right thing.
    • We are one team working toward a common goal.
    • We are each responsible for our customers’ experience.
    • We practice open communication at all levels of the company to foster individual, team and company growth.
    • We actively participate in efforts to improve our communities-internal and external.
    • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.


    Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.


    Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.  Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.


    Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.


    PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.


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