The State Regulatory Guidance (All Plan letters) responsibilities include, but are not limited to:
- DHCS All Plan Letter (APL) and Policy Letter (PL) Applicable Notices
- DHCS All Plan Letter (APL) and Policy Letter (PL) - Non-Applicable Notices
- Submits proof of APL and PL compliance documents to DHCS
The Organization Risk Assessment responsibilities include, but are not limited to:
- Review of new potential risks with assigned accountable business owners
- Provide final data set to senior executive team for implementation of agreed upon interventions
The Regulatory Audit Process responsibilities include, but are not limited to:
- Creation of audit folders
- Tracking of documents/universe and requests received from the auditor and distributed to the business owners
- Audit Readiness Questionnaires
The Regulatory Routine Reporting responsibilities include, but are not limited to:
- Maintaining calendar for all regulatory compliance
- Tracking timeliness of business owner’s submissions and attestation
The Enterprise Monitoring and Oversight workstream responsibilities include, but are not limited to:
- CMS Program Audit universe scrubber (for all universes)
The Federal Regulatory Guidance (CMS HPMS memos) responsibilities include, but are not limited to:
- Tracking of regulatory guidance changes (2017 Medicare Marketing Guidance Changes)
- Maintenance of the 2018 Call Letter Grid that illustrates deliverables by business units
Audit and CAP
The Internal Audit workstream responsibilities include, but are not limited to:
- Review of prior and current year ORA risks
- Initiates Management Action Plans (MAP) for all audits that produce findings
Pre-Delegation Audit, Healthcare Delivery Organization (HDO) Credentialing, HDO Initial Credentialing, HDO Re-credentialing and Re-credentialing.
- Facility Site Review audits, specifically audit of medical facilities/sites
- Medical Record Review audits, specifically audit of medical records
- Utilization Management audits include:
- UM audits
- Quality Management (QM) audits
- Special Needs Plan (SNP) audits
- Service Denial audits
Credentialing, Facility Site Review (FSR), Medical Record Review (MRR) and Utilization Management (UM).
- Credentialing audits include:
- Adverse Action Monitoring
- Annual Credentialing
- Credentialing Initial File
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