Regulatory Compliance Audit Specialist id-12200
About the position
The Customer Solution Center (CSC) Audit Readiness Specialist II is responsible for the execution, oversight, and monitoring of the guidelines and protocols to ensure readiness for all regulatory audits. This position will develop, with the assistance of CSC management, a successful auditing strategy for the following end-to-end processes within CSC (i.e. Enrollment processing timeliness and accuracy of loading members, timeliness of I.D. Card and member materials, outbound health risk assessment (HRA) calls for Seniors and People with Disabilities (SPD) and Cal MediConnect (CMC) plus HIF for L.A. Care Medi-Cal Direct program (MCLA), call documentation and categorization, service authorization request and coverage determination, Appeals and Grievances across all lines of business).
This position is responsible for the ongoing progression and maintenance of CSC's compliance program efforts, including, but not limited to, policy and procedure development, training and education initiatives, and compliance programmatic developments and enhancements. This position will complete targeted, focused and random audits related to member interactions and outcomes to ensure all elements are compliant. These results will be provided to management with recommendations and/or corrective actions required to remediate the deficiencies.
This position will be responsible for the regulatory obligations for each line of business and their governing bodies; California Department of Health Care Services (DHCS), Department of Public Social Services (DPSS), Centers for Medicare and Medicaid Services (CMS), LACC - CalHers, and National Committee for Quality Assurance (NCQA) along with review and analysis of regulatory requirements for all product lines. The position will take lead in all of the audit situations and be prepared to present and report full findings and ensure action plans are created, executed, and verified through reconciliation of end to end on all regulatory functions.
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Responsibilities
- Perform audit procedures for Customer Solution Center departments to ensure readiness.
- Identify and define issues, develop criteria, review and analyze evidence, and document business unit processes and procedures.
- Conduct interviews, review documents, develop and administer surveys, compose summary memos and prepare working papers.
- Identify, develop, and document audit issues and recommendations using independent judgement concerning areas being reviewed.
- Communicate or assist in communicating the results of audit and consulting projects via written reports and oral presentations to Customer Solution Center management.
- Collaborate with business units in audit universe preparation and validation.
- Assist in document preparation for regulatory and internal audits.
- Work closely with Customer Solution Center Management to determine and handle effectiveness/accuracy of operational processes.
- Collaborate with internal Subject Matter Experts (SMEs) to understand Customer Solution Center regulatory processes.
- Evaluate policies and procedures with applicable regulations/guidelines and provide recommendations to management for continuous process improvements.
- Collaborate with Customer Solution Center Business Analyst to track, trend, and analyze results of Quality Assurance (QA) scorecards for training and quality improvement.
- Perform other duties as assigned.
Requirements
- Bachelor's Degree or equivalent education and/or experience.
- A minimum of 5 years of experience in regulatory auditing (Appeals & Grievances, Call Center, Enrollment) in a healthcare environment.
- Previous experience with Medi-Cal and Medicare in a managed care environment.
- Advanced computer proficiency in Word, Excel, and Access.
- Strong analytical and team building skills.
- Ability to work effectively with diverse team members.
- Ability to formulate recommendations to improve quality and service delivery.
- Ability to multi-task and streamline day-to-day operations.
- Ability to track and trend and create regulatory reporting.
- Strong interpersonal and organization skills.
Nice-to-haves
- Tableau experience.
Benefits
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
