Compliance Auditor - CMS (Medicare)

Job Details

Job Location
Main Office - Santa Barbara, CA

Position Type
Full Time

Job Category
Audits, Monitoring, & Oversight

Description

Salary Range: CA Central Coast 95,062 - 137,840

Job Summary

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey, and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Under the direction and supervision of the Audits, Monitoring, and Oversight (AMO) Manager, and through collaboration with Directors and Management level staff, this position directs and conducts audit activities of varying complexity and supports initiatives of moderate to complex difficulty related to CenCal Health's AMO program. This includes the performance of routine and complex AMO activities of internal departments and external partners to ensure compliance with Medi-Cal and Medicare regulatory and contractual requirements, and operational plan requirements, as well as drafting, reviewing, and coordinating corrective action plans.

Duties and Responsibilities:

GENERAL:

• Directs and conducts routine and complex compliance audit activities of internal departments and/or external partners, documenting results in audit work papers, developing detailed document request lists, conducting audit conferences and walk-throughs, and proposing recommendations for improvement.
• Contribute in the new implementation and review of documented audit processes to ensure compliance against requirements including contractual, Federal, State, the Centers for Medicare and Medicaid Services (CMS), and the National Committee for Quality Assurance (NCQA) standards.
• Directs and conducts regulatory research to identify gaps and provides an interpretation of regulations to ensure appropriate application.
• Develops audit scope and audit tools based on regulatory compliance against state and federal regulatory requirements and standards, including those issued by the California Department of Health Care Services (DHCS), the California Department of Managed Health Care (DMHC), NCQA, and CMS requirements.
• Writes clear and concise audit reports based on audit results, ensuring accuracy and quality of audit reporting and utilizing knowledge to determine findings.
• Develops and implements quality improvement and corrective action plans (CAPs) based on risk analysis, audit findings, or delegate performance, to ensure evidence of corrective actions are in place.
• Maintains CenCal Health's risk logs and audit tools.
• Directs and conducts routine monitoring activities to ensure compliance with regulatory and contractual requirements.
• Creates reports and analyzes data for reporting to management, the Delegation Oversight Committee, Compliance Committee, and Board of Directors.
• Responsible for audit announcement notices and memos.
• Directs and conducts audits of assigned areas, including performing various audit procedures and documenting audit findings.
• Performs follow-up audits to determine if action has been taken action to mitigate the identified risks.
• Provides independent evaluations and maintains operational controls, tools, policies, and procedures.
• Develops audit materials for entrance and exit conferences.
• Trains internal audit participants/ business owners on audit process and/or tools.
• Complies with HIPAA, Privacy, and Confidentiality laws and regulations.
• Other duties as assigned.

SPECIALIZATION:

• Independently oversees coordination of internal audits with a focus on Centers for Medicare & Medicaid Services (CMS) requirements.
• Audits to ensure compliance with Federal and State regulatory requirements, the DHCS Medi-Cal Managed Care Contract, Medicare Advantage and Medicare Part D regulations and guidance, the DHCS State Medicaid Agency Contract (SMAC), Delegation Agreement, Health Plan Management System (HPMS memos, All Plan Letters (APLs), Policy Letters (PLs), CenCal Health policies and procedures, and National Committee for Quality Assurance (NCQA) standards, as applicable.
• Contributes to the Delegation Oversight Committee by ensuring First Tier, Downstream, and Related Entities oversight reporting from stakeholders are clear, accurate, and concise. Compile meeting packets, and work with AMO management in preparation for quarterly meetings.
• Presents to committee members on emerging topics or concerns related to First Tier, Downstream, and Related Entities and delegation oversight for CMS.
• Assists with external regulatory audit activities, as assigned.

Qualifications

Knowledge/Skills/Abilities:

Required:

• Extensive audit experience with DHCS, CMS, DMHC, and/or NCQA and understanding of audit standards and requirements;
• Excellent written and verbal communication skills with strong business writing aptitude;
• Experience researching, compiling, and organizing information from various sources;
• Strong organizational skills and attention to detail;
• Strong skills in problem identification, analysis, resolution, organization, and prioritization;
• Demonstrate ability to accurately apply and interpret clinical guidelines;
• Ability to work productively with all Plan staff;
• Ability to coordinate work between departments;
• Ability to work with minimal supervision, both independently and in teams;
• Ability to reprioritize workload as needed; and
• Attention to detail and accuracy.

Desired:

• Internal healthcare auditor certification (or ability to achieve certification within 1 year);
• Certified Health Care Compliance (CHC) certification (or ability to achieve certification within 1 year); and
• Experience in managed health care and health care compliance.

Education and Experience:

• Advanced degree - Bachelor's (preferred) or Associate's Degree; and
• 2+ years of compliance or auditing experience in a healthcare environment.