Regulatory Compliance Auditor

Location: Orange, CA
Date Posted: 05-02-2018
Regulatory Compliance Auditor – Managed Care​
Orange, CA
*** This is a Full-Time, Benefits Available, CONTRACT opportunity, expected to last several months, or longer! ***
** Must be willing and able to travel (mileage reimbursed) to area provider offices, if needed (35%). **
Your Job Summary:
The Regulatory Compliance Specialist / Auditor will provide facilitation, coordination, planning, implementation, oversight, auditing, monitoring, and ongoing operational support related to contracted requirements and related activities within the health plan and its delegated network.  They will coordinate and collaborate with internal and external stakeholders to ensure all contractually required measures are being followed and tracked.  The Quality Compliance Auditor will be accountable for the management and overall oversight of compliance with government contract requirements, and state/federal regulations. 
Your Background:
Requires Bachelors’ degree in Healthcare or Business Administration, or related field, or additional years of experiance.
Demonstrated expertise in health plan operational, financial, quality assurance, and compliance regulations required.
Around 2-3 years of experience in Claims, Customer Service or Credentialing.
At least 2 years of Quality Improvement related experience in a health plan or other Managed Care Organization (HMO, Medical Group/IPA, TPA/MSO); Medi-Cal experience highly preferred.
Around 3-5 years working in a Managed Care setting, including experience with guidelines for Medicaid and related state programs, is highly preferred.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
Ability to analyze and integrate information and make sound decisions based upon established guidelines.
Resourcefulness as demonstrated by the effective application of professional knowledge to new situations.
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
Experience in training / teaching staffs to meet operational requirements and goals.
Strong oral and written communication skills; ability to interact with all levels of internal and external contacts.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
Must be willing and able to travel to area provider offices, if needed (35%).
Your Duties: 
  • Coordinates the execution of contract requirements and related compliance actions related to the state program.
  • Monitors and ensures timely, accurate and appropriate submission of contract deliverables and of all state filings related to health plan licensure.
  • Coordinates responses to state agency inquiries, including state agency administrative reviews, audits, corrective actions and ad hoc visits.
  • Researches laws, regulations, guidelines, contracts, policies, procedures and other types of resources or documentation specific to Medicare. Analyzes and interprets such information and make recommendations to ensure compliance with Medicare requirements.
  • Participates in risk assessment activities relative to Medicaid, identifying and resolving inefficiencies, training staff on compliance requirements and controls. 
  • Assists in preparing material for all audits (internal, external, mock, or regulatory), and due diligence activities. May include the collection, preparation, review, and submission of information, data, and documents to Medicare compliance officer, regulators, or auditors.  Requires accurate tracking and recordkeeping; coordinating facility audits or interviews; and creating/delivering presentations.
  • Designs and implements programs, policies, and practices to be fully compliant with state and federal contracts, as well as legal and regulatory requirements.
  • Oversees the health plan policies and procedures for full federal and state regulatory compliance.
  • Facilitates the administrative review process with appropriate state agencies, including the corrective action updates that result from less than full compliance on the review standards.
  • Provides technical assistance to staff regarding contract deliverables requirements and any changes to requirements by contract amendment.
  • Interacts with other compliance department personnel on fraud and abuse prevention efforts.
  • Validates state and federal deliverable reports for accuracy and verifies timeliness of submission including ad hoc requests for information, CAP submissions and audit information.
  • Conducts oversight audits of health plan procedures and processes to verify compliance with contractual and regulatory requirements and to identify fraud, waste and program abuse.
  • Manages compliance software functions: enters all correspondence from state agencies and opens needed actions for tracking; enters deliverables along with deliverable due dates; enters ad hoc requests for information along with the due dates.
  • Manages training programs for all health plan staff as required by contract and applicable regulatory requirements.

David DiVito
Division Director
CareNational Healthcare Services
480.425.2451 (CALL – TEXT – FAX)
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