INLAND EMPIRE HEALTH PLAN

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Compliance Auditor II

at INLAND EMPIRE HEALTH PLAN

Posted: 10/3/2019
Job Reference #: 3475
Keywords: compliance

Job Description

Job Requisition ID: 3475 

 

Position Summary/Position

Under the direction of the Audit Manager, the Compliance Auditor is responsible for the auditing of IEHP internal departments, and external review of IEHP delegates, Pharmacy Benefit Manager (PBM) and other administrative contracts to ensure regulatory and contractual compliance requirements.

Major Functions (Duties and Responsibilities)

1. Audit internal departments to ensure compliance with the Seven (7) Elements of an Effective Compliance Program.
2. Conduct pre-contractual reviews of contracts and annual audits of IEHP’s delegates.
3. Perform risk assessments during audit planning and participate in the development of the audit scope, audit schedules, and deliverables.
4. Develop and maintain audit tools based on regulatory compliance with DHCS, DMHC and CMS requirements.
5. Document all compliance activities in the IEHP Compliance 360 database in accordance with department polices and/or workflows.
6. Prepare audit results, identify trends and make recommendations for improving business processes for presentation to the Audit & Monitoring Sub-Committee.
7. Validate the effective implementation of corrective action plans (CAPs) from internal departments & delegates to ensure appropriate completion and make necessary recommendations as needed for compliance.
8. Assist the Audit Manager in the development and maintenance of P&Ps regarding auditing procedures.
9. Establish and maintain effective working relationships with others throughout the organization.
10. Coordinate, prepare, and monitor special projects as needed.

Supervisory Responsibilities
Leading: Self
Experience Qualifications

Four (4) years of managed care experience working with one or more of the following areas: Utilization Management, Claims, Pharmacy Operations, Compliance, FDR oversight activities, Quality Management, Care Management, and/or Grievances and Appeals. Experience with interpretation and/or implementation of Medicare, Medi-Cal managed care regulations is required. At least one (1) year of experience in managed care auditing.

Preferred Experience
Education Qualifications

Bachelor’s degree from an accredited four (4) year institution required.

Preferred Education
Professional Certification

Pursuing, or attained, applicable audit or compliance designation (e.g. CPA, CIA, CFE, CISA, CHC, CHPC) or other related certification.

Professional Licenses
Drivers License Required
Knowledge Requirement

Qualified candidate should possess strong analytical and problem-solving skills and have Managed Care auditing experience to ensure compliance with regulatory guidance. Candidate must possess an understanding of Medicare Advantage, Part D, and managed Medicaid and related regulations. Candidate must also have experience working with firm deadlines, able to interpret and apply regulations. Must be proficient MS Office applications. Knowledge of healthcare related computer systems/applications (MedHok, Compliance 360) helpful. Experience in a Health Care Operations, Pharmacy, Clinical environment preferred.

Skills
Abilities Requirement
Commitment to Team Culture

Commitment to Team Culture: The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

Data entry involving computer keyboard and screens, filing and copying of records and/or correspondence.

Physical Requirements

 

Starting Salary: $49,192.00  - $62,004.00  

Pay rate will commensurate with experience

 

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.