Plan, direct, and coordinate audit and review activities to ensure compliance with regulatory standards. Assists with the implementation of the compliance work plan for the managed care plans. Responsibilities focus on coordinating the response to external audits and conducting internal compliance audits to ensure compliance with contractual and regulatory requirements.
1. Works collaboratively with the management team to monitor adherence to, and document compliance with, regulatory and contractual requirements:
a. Assists in developing and modifying compliance work plan and prioritizing audit/review topics.
b. Assesses compliance or operational risks and helps to develop risk management strategies
c. . Designs compliance audits/reviews to ensure compliance with regulatory standards.
d. Collects and analyzes data in conjunction with audit protocols or the equivalent. Ensures that documentation meets regulatory standards.
e. Prepares statistical and narrative reports based on findings and incorporates findings into presentation media
f. Documents and prepares clear, concise audit reports and other narrative summaries for staff, management, and governing bodies.
2. Maintains relevant statistics as they pertain to regulatory compliance
a. creates and assists with completing Excel or other reports for special projects when applicable.
b. maintain monthly statistics by program
3. Assists with the updating and revising of policies and procedures, which reflect governmental regulations, contractual obligations, and the like.
4. Assists in the coordination of external audits and internal investigations, including exercising discretion and maintaining confidentiality in conducting audits, reviews, and investigations.
5. In general:
• Proactively identifies problems or issues and takes lead in resolving issues.
• Demonstrates creativity in finding solutions.
• Demonstrates ability to influence and enlist support.
• Demonstrates ability to diagnose problems.
• Demonstrates ability to diagnose and coach on related issues.
• Demonstrates clear and concise report writing and presentation skills
• Demonstrates strong research and data interpretation skills/secondary research resources (i.e., Internet).
• Demonstrates interpersonal skills.
• Demonstrates a strong self-initiative and self-motivation.
• Demonstrates effective time, organizational and prioritization skills.
Formal Education: Bachelor's Degree
Experience: 3 years
License, Registration, and / or Certification Requirement: No
Minimum three years prior experience working with a compliance program, member services, enrollment or provider relations desired
Background in Medicare and Medicaid programs.
Strong interpersonal and communication skills.
Clear, concise writing and presentation skills.
Strong orientation to deadline and detail
Decisive and exercises good judgment under pressure.