The Job

Performs various oversight and audit activities to ensure compliance with CMS and local requirements. This may include: testing, monitoring, documenting and reporting the overall level of compliance with CMS and local requirements for designated audit area (Authorizations, Credentialing, Compliance Programs, Claims, Utilization Management, Special Needs Plan, etc.) achieved by SCAN internal operations and First Tier, Downstream, and Related Entities (FDR); and/or monitoring and auditing CMS required data submissions to ensure compliance with CMS regulatory requirements.

You Will

Performs on-site and desktop auditing of SCAN internal processes and FDRs including SCAN's delegated groups, IPA's, hospitals and ancillary providers in accordance with CMS and DHCS and contractual requirements to ensure compliance Recognizes and communicates areas for improvement to network providers
Prepares detailed written results of oversight audits by communicating findings, areas of concern and recommendations for improvement, including corrective action requests in accordance with P&P's Makes recommendations for development of policies and procedures, as well as work flow charts
Conducts closing meetings with audited providers to give them a preliminary overview of completed compliance audits 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 Responds to audited providers as disagreements with audit findings arise Analyzes submitted reports from providers, including the request for corrections from providers as needed Communicates regulation interpretations and explains their application, provides supplemental information if needed Conducts detailed review, analysis, and interpretation of legislative, statutory, regulatory, and contract language
Conducts all aspects of annual oversight projects, including creation and distribution of mass mailing and individual correspondence; coordination of projects with internal SCAN staff and departments; monitoring and reporting delegated compliance; tracking, trending and reporting upon project status; coordinating with Compliance regarding report submissions and HPMS/regulatory updates Uses critical thinking skills and identifies impactful areas for provider data requirements to develop an effective implementation and communication plans
Functions as the service delivery compliance subject matter expert by representing the Delegation Oversight Unit (DOU) in interdepartmental meetings and partnering with Compliance to develop and implement SCAN policy regarding NCQA, DHCS, CMS and/or other regulatory revisions Utilizes department desktop procedures, workflows, job aids and training material Escalates longstanding issues of non-compliance in accordance with P&P's Identifies barriers and brings to the attention of the supervisor/manager
Educates providers on such topics as compliant delegated claims processing and the denial of claims with member liability in accordance with CMS, local state and SCAN contractual requirements Maintains the member's right to privacy and protect SCAN operations by keeping information confidential
Reviews letters from internal and delegated administrators, Compliance Program processes, or data submissions for accuracy and compliance with CMS and contractual requirements, and recommends delegation status based on results Adheres to all quality, compliance and regulatory standards to achieve SCAN outcomes

This role requires driving in assigned territory.

We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.

Actively support the achievement of SCAN's Vision and Goals.

Other duties as assigned.

Your Qualifications

Associate's Degree or equivalent experience

0-3 years of related FSR Auditing experience.

Performs work under direct supervision.

Handles basic issues and problems, and refers more complex issues to higher-level staff.

Possesses beginning to working knowledge of subject matter.

Technical expertise - Basic technical skills for functional area
Problem Solving - Basic problem-solving skills
Communication - Good communication and interpersonal skills

This role requires driving in assigned territory

What's in it for you?

• Base Pay Range: $38.61 to $55.86 per hour
• Work Mode: Remote/Field (This role requires driving in assigned territory)
• 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!