The Job

Supervises a team of auditors that participate in financial, operational, compliance, or information technology audit programs.
Performs and provides oversight to the Managed Care Plan's (MCP) Department of Health Care Services (DHCS) auditing team responsible for conducting and overseeing both initial and subsequent reviews of Primary Care Provider (PCP) sites. These reviews include a Facility Site Review (FSR) and a Medical Record Review (MRR), utilizing the tools and standards set by DHCS. The site review process is an integral part of the MCPs quality improvement programs, focusing on each PCP site's capacity to provide safe and effective clinical services.

Creates and distributes monthly audit assignments, ensuring all required audit activity completed within established timelines. Confirm all audit documentation is comprehensive and adheres to regulatory and compliance requirements.
Assists manager in reviewing team metrics, workload and works with CMT to maintain team CSR certifications.
DHCS certifies and designates CMT for Managed Care Plans (MCP). CMTs must maintain their certification and provide training, supervision, and assistance to help maintain MCP's Certified Site Reviewer (CSR) certifications.

Your Responsibilities

1 Conducts detailed review, analysis, and interpretation of DHCS All Plan Letters (APL) and works with manager to deploy. Using critical thinking skills, identify impactful areas for regulatory compliance to develop an effective implementation communication plan.
2 Facilitates the auditing of SCAN contracted and collaborative PCP offices that see Medi-Medi members, in accordance with CMS and DHCS and contractual requirements to ensure compliance. Provides training on all aspects of auditing and post audit documentation, providing feedback and identifies opportunities for improvement.
3 Prepares detailed reports of audit activities of oversight audits by communicating findings, areas of concern and recommendations for improvement, including corrective action requests in accordance with P&P's.
4 Assists the clinical team in responding to audited providers as disagreements with audit findings arise. Communicates regulation interpretations, relevant standards and explains their application. Provides supplemental information if needed.
5 Functions as the service delivery compliance subject matter expert by representing the Delegation Oversight Unit (DOU) in interdepartmental and county collaborative meetings. Partners with Compliance to develop and implement SCAN policy regarding NCQA, DHCS, CMS and/or other regulatory revisions. Escalate longstanding issues of non-compliance in accordance with P&P's.
6 Educates Providers, SCAN staff and Compliance Auditors on regulatory requirements and operational process changes in accordance with CMS, local state and SCAN contractual requirements. Provides feedback on audit documentation, identifies opportunities for improvement.
7 Assists providers in achieving and maintaining compliance with SCAN, Federal, State and NCQA requirements and guidelines including the development and implementation of corrective action plans (CAP), monitoring CAP activities and providing education and tools. Provides direction on audit related questions from auditor team and/or coordinators, mentors new employees and serves as the Subject matter expert (SME) with all stakeholders. Serves as a resource and assists with escalated issues and tasks, as needed. Know when to refer questions to management. Utilizes/revises department desktop procedures, workflows, job aids and training material. Identifies barriers and brings to the attention of the supervisor/manager. Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies. Facilitates and prepares clinical team for didactic and Inter-Rater Reliability trainings.
8 Administer policies and procedures that ensure compliance with applicable laws, regulations, and standards. Monitors the regulatory environment and assists in the development of strategies for responding to new or amended legislation.

Your Qualifications

• Associate's Degree or equivalent experience, Bachelor's Degree preferred
• 5 to 7 years in an HMO, IPA, MSO or, auditing and training experience required.
• DHCS Certified site reviewer required.
• DHCS Master Trainer required.
• Demonstrated understanding of current CMS and DHCS compliance requirements.
• Excellent written and verbal communication skills.
• Strong independent analytical, critical thinking, problem solving, and decision-making skills.
• Strong attention to detail and organizational skills.
• Strong customer service skills.
• Ability to prioritize multiple and competing tasks in a fast-paced environment.
• Must be able to work independently as well as in a team environment.
• Proficient in MS Office and data entry. Strong contract interpretation skills.
• Primary duties are home office based, approximately 20% of travel time. Primarily local travel.
• Ability to work as part of a team. Written communication skills.
• Ability to identify and seek needed information/research skills.
• Analytical thinking skills.
• Detail oriented.
• Ability to meet deadlines.
• Mathematical skills. Accounting skills.

What's in it for you?

• Base Pay Range: $92,400 to $133,671 annually
• Work Mode: Mostly Remote
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO) along with 11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days
• Excellent 401(k) Retirement Saving Plan with employer match
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!