Medicare and Medi-Cal Compliance Auditor II at Health Plan of San Mateo

, California, United States -

Full Time

Start Date

Immediate

Expiry Date

02 Jan, 26

Salary

0.0

Posted On

04 Oct, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Auditing, Regulatory Compliance, Managed Care, Healthcare Auditing, Quality Assurance, Analytical Skills, Communication, Teamwork, Problem Solving, Microsoft Office Suite, Corrective Action Plans, Risk Assessment, Public Health Programs, Delegation Oversight, Internal Auditing, Research Skills

Industry

Hospitals and Health Care

Description

Only Open to California Residents HPSM does not generally pay for relocation. General Description Under general direction of the Government and Regulatory Affairs manager conduct internal and external audits that are routine and complex. Act as a subject matter expert resource to HPSM staff by providing a comprehensive explanation and interpretation of regulations and applicability to audits and audit findings. Duties & Responsibilities Essential Functions: Independently create and maintain auditing tools in accordance with standards and regulations established by: the Department of Health Care Services (DHCS), the Department of Managed Health Care (DMHC), the Centers for Medicare and Medicaid Services (CMS), the Health Industry Collaboration Effort (HICE), the National Committee for Quality Assurance (NCQA), HPSM policies and procedures, and all other applicable regulations. This includes updating all audit tools no less than annually, and when new regulations and guidelines are published. Prepare business owners for audits from regulatory agencies, including but not limited to: compiling, requesting, and distributing materials as appropriate. Compose and issue pre-audit guidance to business owners within defined timeframes. Conduct routine and focused audits within defined timelines with minimal supervision, with clear communication and follow up to participating business owners regarding timelines and deliverables. This includes conducting audits of critical operational functions using tools to monitor compliance with contracts, regulations, and program guidelines. Lead and coordinate the scheduling of internal and delegation oversight audits including annual, focus, and ad hoc audits. Ensure internal and external stakeholders are kept fully and accurately informed of information related to audit activities; this includes responsibility for writing and delivering all formal correspondence regarding audits to business owners and delegates, such as pre-audit and post-audit communications, corrective action plans, and letters of non-compliance. Maintain accurate record keeping of all delegation oversight and internal audits and ensure all deadlines are met. Following internal or external audits, prepare detailed and summary post-audit reports and communicate findings to the delegate or internal business owners; this includes the ability to independently answer delegate/business owner questions regarding the content of the findings and to create reports that can be used by management. Review audit materials and create appropriate corrective action plans as needed, including generating recommendations to management regarding organizational risk, potential penalties, or sanctions. Monitor progress of corrective action plans and escalate barriers or issues when a corrective action plan is not being met. Maintain knowledge of HPSM policies and procedures for standard work processes of those departments audited. Summarize and present the scope of audits and details regarding corrective action plans to the Compliance and Delegation Oversight committees. Act as a subject matter expert on audits and regulatory requirements; this includes effectively communicating the scope of audits or regulations and answering questions from the Compliance Auditor I, internal staff, delegate representatives, or others as applicable within committee meetings. Use a strong knowledge of regulatory requirements and business operations to make appropriate suggestions to business owners and management within the scope of an audit, to improve organizational compliance. Consult with management on leveraging and imposing contract sanctions when appropriate. Secondary Functions: Perform other duties as assigned. Qualifications The following represents the typical way to achieve the necessary skills, knowledge and ability to qualify for this position: Education and experience are equivalent to: Bachelor’s degree in the field of health, business or public administration. Five (5) or more years of professional experience in a managed care environment. Three (3) years’ prior healthcare auditing experience. Knowledge of: Managed Care policy and operations, and the regulatory requirements pertaining to Medi-Cal, Medicare, and the Knox Keene Act. Delegation Oversight auditing, principles and requirements. Internal auditing, quality assurance, and/or quality improvement processes. Public health programs. Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint. Abilities: Work cooperatively with others. Work as part of a team and support team decisions. Communicate effectively, both verbally and in writing. Use sound professional judgement to identify and escalate high risk audit findings to management and provide detailed information with examples. Adapt to changes in requirements/priorities for daily and specialized tasks. Demonstrate strong analytical and research skills. Communicate effectively, orally and in writing, particularly in preparing reports. Interact with a variety of people in difficult situations. Meet deadlines. Work independently Prioritize and work on multiple assignments concurrently to ensure deadlines are met. Act as a subject matter expert on applicable knowledge areas.

Responsibilities

Conduct internal and external audits, acting as a subject matter expert on regulations and audit findings. Prepare business owners for audits and ensure compliance with contracts and regulations.