- Full Time/Contract
- Rancho Cucamonga, CA
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company to Work For, "Favorite Training Program, and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.
Compliance Auditor II
Under the direction of the Audit Manager, the Compliance Auditor is responsible for the auditing of Company internal departments, and external review of Company delegates, Pharmacy Benefit Manager (PBM) and other administrative contracts to ensure regulatory and contractual compliance requirements.
- Audit internal departments to ensure compliance with the Seven (7) Elements of an Effective Compliance Program.
- Conduct pre-contractual reviews of contracts and annual audits of Company’s delegates.
- Perform risk assessments during audit planning and participate in the development of the audit scope, audit schedules, and deliverables.
- Develop and maintain audit tools based on regulatory compliance with DHCS, DMHC and CMS requirements.
- Document all compliance activities in the Company Compliance 360 database in accordance with department polices and/or workflows.
- Prepare audit results, identify trends and make recommendations for improving business processes for presentation to the Audit & Monitoring Sub-Committee.
- Validate the effective implementation of corrective action plans (CAPs) from internal departments & delegates to ensure appropriate completion and make necessary recommendations as needed for compliance.
- Assist in the development and maintenance of P&Ps regarding auditing procedures.
- Establish and maintain effective working relationships with others throughout the organization.
- Coordinate, prepare, and monitor special projects as needed.
- Perform other duties as assigned to ensure the Health Plan operations are successful.
- Ensure the privacy and security of PHI (Protected Health Information) as outlined in Company’s policies and procedures relating to HIPAA compliance.
SKILLS & QUALIFICATIONS
- Bachelor’s degree from an accredited four (4) year institution is required.
- Pursuing, or attained, applicable audit or compliance designation (e.g. CPA, CIA, CFE, CISA, CHC, CHPC) or other related certification.
- 4 years of managed care experience working with one or more of the following areas: Utilization Management, Claims, Pharmacy Operations, Compliance, FDR oversight activities, Quality Management, Care Management, and/or Grievances and Appeals.
- Experience with interpretation and/or implementation of Medicare, Medi-Cal managed care regulations is required.
- At least (1) year of experience in managed care auditing
- Qualified candidate should possess strong analytical and problem-solving skills to ensure compliance with regulatory guidance.
- Candidate must possess an understanding of Medicare Advantage, Part D, and managed Medicaid and related regulations.
- Candidate must also have experience working with firm deadlines, able to interpret and apply regulations. Must be organized, detail oriented, able to exercise strong independent judgment; possess conflict resolution and persuasion skills. A team player with excellent communication and presentation skills; must be able to work effectively with various internal departments/levels of management; external plan partners, IPAs and other external agencies.
- Must be proficient MS Office applications. Knowledge of healthcare related computer systems/applications (MedHok, Compliance 360) helpful. Experience in a Health Care Operations, Pharmacy, Clinical environment preferred.
COMPENSATION | POSITION CLASSIFICATION
$27 to $31/hr.
Full-Time | Contract Assignment