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Compliance Auditor, Fairfield, CA


Organization: Partnership HealthPlan of California
Category: Professional
Location: Fairfield, CA
Date Job Posted: December 1, 2021
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Compliance Auditor

Job ID 2021-2072 FLSA Status Exempt

Overview

Under supervision and direction of the Compliance Oversight Manager, this position provides support and coordinates plan-wide auditing activities; including coordinating external audits, corrective action plans, and maintaining the internal audit program. This position supports the plan’s compliance program and assists in efforts to be compliant with applicable laws, regulations, and policies.

Responsibilities

  • Follows up with departments on implementation of requirements for State Regulatory Management.
  • Responsible for audit coordination for State Regulatory Management.
  • Works on regulatory changes and implementations.
  • Expands participation in Kaiser annual audits.
  • With the Delegation Specialist, leads annual NCAL audit – weekly calls with plans to develop pre-audit materials, coordinates with departments, conducts sample selection, reviews P&Ps, audits CGA cases onsite, develops CAP to issue to Kaiser, and closes out audit.
  • With the Delegation Specialist, works with delegated entities on compliance issues and develops long-term shared projects to improve processes between operations.
  • Optum, Delta Dental, VSP, and Beacon data validation – reviews delegated entities ODR quarterly reports, analyzes data, and performs quality checks to ensure compliant for annual MDV audit.
  • Pre-delegation audit on Beacon – develops tool, reviews compliance P&Ps, and provides report to Beacon.
  • With the Delegation Specialist, performs annual audits on provider delegates including medical groups.
  • Leads external audits with state and federal government (DHCS medical audit, CMS MDV audit, Financial 1/3 audit, etc.).
  • Coordinates with departments to submit documentation for external audits.
  • Works with auditors to communicate responses and departments to receive all communication.
  • Responsible for putting together plan’s rebuttals and CAP responses reports for external audits.
  • Coordinates onsite audit reviews and debriefs with departments.
  • With the Compliance Unit, meets with departments and coordinates action plans, addresses findings until resolved.
  • Develops internal audit tools and audits materials with requirements.
  • Performs internal audits based on compliance issues and addressing past audit findings.
  • Works with departments to address audit notification and prepares documentation.
  • Performs sample selection and reviews case files.
  • Develops audit report based on findings and reviews draft with departments.
  • Performs audits on Optum, Delta Dental, and VSP:
  • Leads audit on delegated entities.
  • Reviews agreements and past findings with departments involved to develop audit specifications.
  • Develops audit notifications and tools.
  • Coordinates all steps between delegate and departments including documentation requests and responses to address any issues.
  • Develops audit report and issues to delegate.
  • Coordinates CAP responses and closes out audit with departments and delegate.
  • With the Compliance Unit, audits departments with delegation reporting, reviews to ensure oversight activities are performed and properly documented so that this can be demonstrated in a DHCS or DMHC audit.
  • With the Compliance Unit, collaborates with satellite and regional offices to standardize plan-wide privacy practice.
  • With the Compliance Unit, maintains Compliance training program, including:
  • New hire compliance training,
  • Annual compliance training – HIPAA, FWA, testing, retention,
  • Circuit training for all departments – topics requested by departments and refresher trainings, and
  • Collects and documents compliance primers.
  • Manages the “Caught You Being Compliant” program.
  • Quarterly random workstation checks for badges and PHI protection.
  • Statistics reported out at all staff and to the Compliance Committee.

Qualifications

Education and Experience

Bachelor’s Degree in Liberal Arts, Communications, Business Administration, Health Care Administration, Political Science ,or related field; two – three (2-3) years of experience in the health care field, managed care experience preferred, with knowledge of the Knox-Keene, Medicare, Medi-Cal, and Healthy Families regulations; or an equivalent combination of education and experience. Experience with health plan audits preferred.

Special Skills, Licenses and Certifications

Highly proficient in applicable business software applications including PC usage, Microsoft Word, PowerPoint, Excel, Project, typing speed of 30 wpm. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Excellent oral and written communication skills. Excellent organizational skills with ability to prioritize assignments, maintain effective filing systems, and meet deadlines. Ability to work under minimal supervision and exercise independent judgment. Diplomacy and tact in handling sensitive information regarding personnel affairs as required. Ability to interact with executives and vendors effectively, handling all assignments with efficiency. Must be able to handle multiple tasks and meet deadlines. Excellent judgment.

Work Environment And Physical Demands

Ability to use a computer keyboard and other business machines. More than 50% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying sizes, weighing up to 35 pounds.

All HealthPlan employees are expected to:

  • Provide the highest possible level of service to clients;
  • Promote teamwork and cooperative effort among employees;
  • Maintain safe practices; and
  • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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