AbleTo, Inc. is a market leader in providing technology-enabled behavioral health care. AbleTo has been treating patients for over eight years, and improves patient outcomes and lowers costs by providing treatment that integrates behavioral and medical health care. AbleTo's structured therapy programs strengthen medical recovery and self-care among members with chronic or complex clinical needs. AbleTo analytics, coupled with our multi-channel engagement platform, identify and engage members with unmet, often undiagnosed, behavioral health needs. A proprietary platform connects individuals and their care teams with AbleTo licensed providers who deliver weekly sessions by phone or video supported by an integrated digitalexperience. AbleTo programs are clinically proven to improve both behavioral health and medical outcomes while lowering overall spend for higher-cost, higher-risk members. AbleTo has contracts with large national and regional payers, and is financially backed by top-tier investors, including Bain Ventures, Sandbox Industries, .406 Ventures, HLM Venture Partners, and Aetna Ventures.
The VP of Compliance (“VP”) leads the development, implementation, and maintenance of system-wide compliance programs, policies, and procedures. The ideal candidate is a dynamic and experienced business leader who is comfortable working at a fast-paced, innovative, and mission-driven company in a highly regulated market. Given AbleTo’s a payer-centric business model, the individual also needs to be comfortable partnering effectively with major payer organizations, ensuring company meets payer and related regulatory requirements and collaborates on approaches to engage and treat members in an evolving regulatory landscape.
- The VP of Compliance reports on a day-to-day basis to the Chief Executive Officer (“CEO”) and works closely with the President on compliance initiatives.
- The VP is independent and should not provide management to operational areas, avoiding the potential for a conflict of interest from the VP’s oversight responsibilities.
- The VP routinely reports Medicare compliance activities to the Board of Directors Compliance Committee, maintaining a direct line of communication. At any time, the VP may escalate compliance issues directly to the executive management team, the Chief Executive Officer, the President, or the Board of Directors, who are accountable for ensuring that AbleTo’s compliance goals are met. The VP’s reports are not filtered through other executive or operational areas.
- The VP is also responsible for providing compliance program guidance and for reporting incidents of suspected or identified non-compliance to senior management and the Board of Directors.
The Primary Responsibilities:
- The VP of is responsible for ensuring that AbleTo meets all regulatory and client-specific requirements for each line of business (Commercial, Medicare, and Medicaid). For example, the VP is charged with the overall responsibility for ensuring that the Medicare Compliance Program is administered according to CMS/Medicare guidelines and regulations.
- The VP also ensures that compliance risk areas applicable to AbleTo are adequately addressed through a focused internal auditing process, an ongoing monitoring process, and a robust reconciliation process.
- In addition, the VP is responsible for establishing key performance measures, metrics, and reporting protocols as part of the organization’s audit and monitoring of key risk areas. It is the responsibility of the VP to monitor and report key compliance and performance metrics for the purpose of resolving any identified patterns and trends, work with operational areas on any internal corrective actions, and assess the effectiveness of the Medicare Compliance Program.
- With the support of AbleTo senior management and the Board of Directors, the VP ensures consistent disciplinary guidelines are enforced for incidents of non-compliance with company standards.
- The VP ensures that policies and procedures relating to compliance and fraud, waste and abuse promote effective interdepartmental and external lines of communication.
- At least quarterly (but more often if necessary), the VP or his/her designee reports to the Board of Directors’ Compliance Committee and the CEO. The VP or his/her designee provides a report of the identification and resolution of suspected, detected or reported instances of noncompliance and AbleTo’s compliance oversight and audit activities. The VP or his/her designee also provides a summary of material violations of state and/or federal laws or the Code of Conduct, and/or the applicable policies and procedures; the nature of the alleged violation; the department involved; the findings of any investigation; and the action taken, as well as a summary of Compliance Hotline calls and their disposition.
Policies & procedures
- Maintain an understanding of and assure compliance with federal and state regulations, industry guidelines, and accreditation agency standards
- Participate with senior management in the establishment or revision of internal control procedures to ensure that adequate protection of the Company is maintained
- Initiate, maintain, and revise policies and procedures for the general operation of the compliance program and its related activities to help prevent illegal, unethical, or improper conduct
- Ensure compliance to relevant internal policies & procedures.
- Work with the Human Resources department and others as appropriate to develop effective compliance training programs, including appropriate introductory training for new employees as well as ongoing training for all employees
- Accreditations may include URAC, NCQA, ASWB ACE, ANCC, ISO 27002, HITRUST, SOC2 and/or others as decided from time to time by the Company
- Help coordinate and monitor the Company’s activities to achieve these accreditations per approved timelines
- Develops, maintain & execute the Internal Audit Plan and related remediation efforts
- Completes regulatory compliance audits to ensure that functional activities are conducted in accordance with Company plans, policies, procedures and applicable Federal and State regulations
- Identify potential areas of compliance vulnerability and risk; develop & implement corrective action plans for resolution of problematic issues, and provide general guidance on how to avoid or deal with similar situations in the future.
- Manage multiple concurrent audits, process flows and effectiveness of control design; assess the impact of non-conforming results across the audited activity
- Prepare for and act as the AbleTo main point of contact for external (e.g. client) audits
- Ensure audits deliver high-quality reports and solid conclusions; provide input into the annual auditschedule
- Drive & track audit remediation milestones per remediation plans communicated internally or with clients, as appropriate
- Coordinate with internal departments to establish quality performance metrics and measurement methods
- Ensure that the continuous improvement process is in place for all areas of quality found lacking
- Prepares quarterly reports to the Audit and Compliance committee and Senior Management detailing compliance initiatives throughout the year as well as recommends improvements/changes in the overall compliance program
- Monitors the performance of the compliance program and related activities on a continuing basis, taking appropriate steps to improve its effectiveness, including periodically reviewing and updating the Standards of Conduct to ensure continuing currency and relevance in providing guidance to management and employees
- Coordinates with legal counsel in response to identified compliance questions, concerns, or federal/state inquires or investigations
- In coordination with the executive team, revises the compliance program to improve its effectiveness or in response to changing organizational needs or new/revised regulations, policies, and guidelines
- Perform special projects and analyses as directed by the Risk Management Committee or Executive Management
- Drive the root cause analysis and corrective/preventative action plans as well as the formal documentation of all incidents (major defects, security and/or privacy incidents)
- Establishes and provides direction and management of the organization’s Compliance hotline. Monitors a log/tracking systems for all Confidential Disclosures through the hotline
- Collaborates with other departments to direct compliance issues to appropriate existing channels for investigation and resolution. Monitors compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends. Consults with legal counsel as needed to resolve difficult legal compliance issues
- Maintain a regular contact with AbleTo’s executive team and departmental heads to promote compliance to quality, security & privacy throughout the organization
- Formally report activities compliance activities in the company’s ongoing Risk Management Meeting
- Member of Senior Leadership Team
- Member of Clinical Quality Committee
- Member of Risk Management Committee (to be formed in 2019)
- Member of Credentialing Committee
- Chairman of Company’s Compliance Committee
- Management representative to Board of Directors Compliance Committee
*Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
- Experience: Bachelor’s Degree. Advance degree (e.g., JD, MPH, MBA) welcome.
- 5-10 years experience in monitoring compliance in the healthcare field
- Experience working with Payer compliance plan, either directly as part of a health plan or as a supplier to health plans.
- Candidate possesses the requisite training and/or experienceworking with government programs and with regulatory authorities in order to maintain and update the Medicare Compliance Program
- Knowledge of the principles and practices of risk management
- Knowledge of healthcare software and word processing experiencepreferred
- Understanding of mental health diagnostic, procedural coding principles and guidelines, state legislation and accreditation standards licensure and requirements
- Ability to communicate effectively with others, orally and in writing
- Ability to work effectively with a broad range of individuals, including other employees, payers, and the public
- Strong problem solving skills, and ability to develop solutions that creatively meet client and regulatory requirements.
- Demonstrate personal traits of a high level of integrity, team orientation, professionalism, and trustworthiness. Places a high value on ethical standards and treating others with dignity and respect
- Ability to work under pressure and handle issues which develop unexpectedly
- Skill in analyzing and evaluating information and data and reaching sound conclusions