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Compliance Auditor, Bakersfield, CA

Organization: Kern Health Systems
Category: Professional
Location: Bakersfield, CA
Date Job Posted: May 3, 2023
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Compliance Auditor

Kern Family Health Care, 2900 Buck Owens Blvd., Bakersfield, California, United States of America Req #1950

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).

KHS reasonably expects to pay starting compensation for the Compliance Auditor position in the range of $30.20- $40.05 / Hourly


Under the direction, of the Compliance Manager, this position is responsible for ensuring the organization's adherence to state and federal regulations. Compliance auditors will complete reviews, monitoring, and auditing activities to determine operational compliance with various requirements , identify areas of non-compliance, and define corrective actions and/or recommend adjustments to internal policies and/or guidelines as needed. The Compliance Auditor’s role is to mitigate risks by analyzing operational processes and to prevent or resolve compliance issues that may pose a negative effect on the company's performance and stability.

Distinguishing Characteristics

The Compliance Auditor will work closely with the Compliance Manager to develop business process improvement recommendations based on findings from both internal and external audits.

Essential Functions

  • Complete reviews, monitoring, and auditing activities to determine operational compliance with various requirements as assigned and/or in collaboration with Compliance Manager.
  • Identifies areas of non-compliance and coordinates corrective actions and/or recommends adjustments to internal policies and/or guidelines as needed.
  • Assists in creating and/or updating audit and monitoring tools to accurately reflect elements audited, scoring, and outcome of audits.
  • Works with stakeholders on rectifying any areas of non-compliance and providing status reports.
  • Assists in the monitoring of existing and proposed regulations to ensure adequate operational compliance of the Plan with changing healthcare requirements.
  • Works on process improvement projects related to audit findings or business controls issues.
  • Performs monitoring of subcontractor to ensure compliance contract requirements
  • Develops and manages work plans to ensure activities and deliverables are completed accurately and on time; negotiates or resolves issues; escalates as needed.
  • Leads data collection activities with internal and external stakeholders through clear and concise verbal and written communication.
  • Compiles and submits reports with written summaries and recommendations to management and stakeholders, including but not limited to operational issues, process changes and activity status.
  • Prepares reports and supporting documentation as required by state, NCQA and other regulators.
  • Assists with the development of and maintains policies, procedures, and processes to ensure adherence to standards and continually improve reporting activities.
  • Participates in DHCS, DMHC, and NCQA strategy, reporting sessions and audit deliverables.
  • Promotes and maintains an environment that supports KHS’s strategy, vision, mission, and values.
  • Organizes meetings, reports out on findings, and captures meeting action items (Compliance Committee, Fraud, Waste and Abuse (FWA) Committee, and Delegated Oversight Committee) meetings
  • Updates job knowledge by participating in educational opportunities like reading professional publications, maintaining personal networks, and participating in professional organizations.
  • Knowledge of general project planning, coordination, and administrative practices.
  • Strong Microsoft proficiency using MS Office Suite: Word, Excel, Outlook, and PowerPoint.
  • Assists in the review and determination of the reliability of management data developed with-in the organization.
  • Coordinates, prepares, and monitors special projects and reports as required.
  • Generates ad hoc reporting for the Compliance Department based on defined activity.
  • Conducts mock audits, both on a prospective and retrospective level and at pre-determined cadences.
  • Evaluates, investigates, and reports on internal and business associates potential HIPAA Privacy and Security incidents.
  • Recommends, establishes business case, and assists management and others in building acceptance of new proposed APLs and procedures.
  • Conduct quarterly privacy reviews to confirm compliance with required safeguards.
  • Works with the Compliance Manager in recommended training and team development activities.
  • Review KHS Anti-Fraud Plan for regulatory or process changes
  • Participate in regulatory FWA meetings and webinars and lead action needed in response to these sessions.
  • Create, maintain and update FWA language for inclusion in materials such as the Compliance Corner, Member Handbook, or provider communications in concert with Directors of these Departments.
  • Complete timely review and disposition of referrals and inquiries in coordination with internal stakeholders.
  • Produces work that is accurate and complete.
  • Produces the appropriate amount of work.
  • Other duties as assigned.

Employment Standard:

Education and Experience

Associates Degree from an accredited institution or equivalent required. Bachelor’s degree in Health Services Administration desired; AND two (2) years’ experience within the operations, claims legal or regulatory support preferably in the health care industry.

Three (3) years’ experience in health insurance and HMO compliance is highly desirable.

Experience in conducting operational quality audits preferred.

Knowledge of:

  • Claims, Utilization Management, and other health plan departmental processes and procedures; project management process; auditing methodologies, reporting tools and analysis, report generation, implementation of business controls.
  • In-depth knowledge of managed care programs and benefits.
  • In-depth knowledge of CMS, DMHC and DHCS requirements, including those related to reporting and oversight.
  • In-depth knowledge of health plan functions and interactions as they relate to compliance and reporting requirements.
  • Knowledge of NCQA requirements related to delegation oversight preferred.

Ability to:

  • Ability to work effectively and efficiently in a deadline-driven environment
  • Adhere to all company policies and procedures relative to employment and job responsibilities
  • Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
  • Rebound from setbacks and adversity when facing difficult situations.
  • Concentrate efforts on the more important priorities towards meeting deadlines in a broader range of activities.
  • Ability to influence without authority, establish direction, build alliances, maintain diverse effective teams, and motivate others.
  • Demonstrate strong problem solving and analytical skills, with ability to determine key issues, develop effective action plans and implement to successful conclusion.
  • Exhibit superior interpersonal skills - interacts effectively with individuals both inside and outside of KHS; relates openly and comfortably with diverse groups of people.
  • Show strong oral and written communication skills, with the ability to communicate professionally to diverse individuals and groups inside and outside of KHS.
  • Proven presentation skills, including but not limited to the ability to tailor presentations to a specific audience, and identify key messages.
  • Commitment to and ability to facilitate the adoption of KHS’s strategy, vision, mission and values.
  • Ability to handle confidential information with appropriate discretion.
  • Adapt to a rapidly evolving work environment; work independently and manage multi-task responsibilities; work well and communicate with a variety of personnel and providers.
  • The most effective and efficient process to get things done, with a focus on continuous improvement.
  • Time management and organizational skills demonstrating the ability to use time effectively and efficiently.

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

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