Job description
Overview:
This role, reporting to the Director, Provider Network Claims and will be responsible for development and implementation of internal Compliance monitoring and audit plans, conducting internal audits and projects related to targeted business functions and processes in order to protect the integrity and reputation of AltaMed. Monitoring and auditing activity will include ensuring compliance with Federal and State regulations, internal controls, formalizing and managing remediation plans to resolve compliance issues and control improvements. The auditor will also be responsible for guiding external audit activity, including facilitating readiness efforts. This position works closely with internal business operations to assist in the successful execution of compliance audit plans and industry standards.
Responsibilities:
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Accomplishes compliance work requirements by orienting, training, assigning, scheduling, and guiding internal audits.
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Assess risks and identify trends to focus internal auditing efforts, including surveying business functions and corporate activities.
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Assist the AVP of claims and Corporate Compliance with the development and implementation of internal monitoring and auditing plans.
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Develops and uses audit tools and industry standards to effectively manage, measure, and improve compliance with regulations and internal controls.
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Conducts audits and projects that evaluate and test the relevant compliance risk, key control points, operational effectiveness, and risk management; audits should include, but are not limited to, medical and related billing/reimbursement.
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Guides and monitors corrective action planning to resolve and/or mitigate identified risks, including working closely with business partners to develop effective business solutions to mitigate risk.
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Works with regulators, business units and external clients to ensure measurement of the proper guidelines, procedures and audit specific trends or newly communicated procedures to ensure compliance.
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Prepare and present written reports to management and the Corporate Compliance Committee, summarizing audit findings and related action planning.
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Assist in the periodic assessment of the corporate compliance program and development of the annual work plan.
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Maintains desktop monitoring system to track performance and measure outcomes related to internal monitoring plans.
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Act as a subject matter expert and assist with the development of claims training process based on internal and external audit results.
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Train, control, supervise and evaluate the performance of assigned staff.
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Attract, retain and develop direct reports.
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Other duties as assigned.
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Bachelor’s degree or equivalent work experience in a managed care setting.
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Minimum 5 years of experience with internal claims auditing, claims examiner or equivalent position
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3+ years of Supervisory experience
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