L.A. Care Health Plan
Customer Solution Center Compliance Audit Specialist II
L.A. Care Health Plan, Los Angeles, California, United States, 90079
Customer Solution Center Compliance Audit Specialist II
Salary Range:
$88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan, serving more than 2 million members in five health plans, ensuring our members get the right care at the right place at the right time.
Mission:
L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Job Summary
The Customer Solution Center (CSC) Audit Readiness Specialist II is responsible for the execution, oversight, and monitoring of the guidelines and protocols to ensure readiness for all regulatory audits. This position will develop, with the assistance of CSC management, a successful auditing strategy for various end-to-end processes within CSC, including enrollment processing timeliness and accuracy, I.D. card issuance, outbound health risk assessment calls, call documentation, service authorization requests, and appeals and grievances across all lines of business. This position is responsible for the ongoing progression and maintenance of CSC's compliance program efforts, including policy and procedure development, training and education initiatives, and compliance programmatic enhancements.
This position will complete targeted, focused, and random audits related to member interactions and outcomes to ensure compliance. Results will be provided to management with recommendations and/or corrective actions required to remediate deficiencies. The position will lead all audit situations, present findings, and ensure action plans are created, executed, and verified through reconciliation of end-to-end regulatory functions.
Duties
Audit readiness:
Performs audit procedures for Customer Solution Center departments to ensure readiness; including identifying and defining issues, developing criteria, reviewing and analyzing evidence, and documenting business unit processes and procedures. Conducts interviews, reviews documents, develops and administers surveys, composes summary memos, and prepares working papers. Identifies, develops, and documents audit issues and recommendations using independent judgment concerning areas being reviewed. Communicates or assists in communicating the results of audit and consulting projects via written reports and oral presentations to management. Collaborates with business units in audit universe preparation and validation. Assists in document preparation for regulatory and internal audits.Regulatory compliance:
Works closely with Customer Solution Center Management to determine and handle effectiveness/accuracy of operational processes. Collaborates with internal Subject Matter Experts (SMEs) to understand regulatory processes and assists with identifying root causes of deficiencies. Evaluates policies and procedures with applicable regulations/guidelines and provides recommendations for continuous process improvements.Collaborates with Customer Solution Center Business Analyst to track, trend, and analyze results of Quality Assurance (QA) scorecards for training and quality improvement.Performs other duties as assigned.
Education Required
Bachelor's Degree. In lieu of degree, equivalent education and/or experience may be considered.
Experience
Required:A minimum of 5 years of experience in regulatory auditing in a healthcare environment required. Previous experience with Medi-Cal and Medicare in a managed care environment.
Preferred:Tableau experience.
Skills
Required:Advanced computer proficiency in Word, Excel, and Access. Strong analytical and team-building skills. Ability to work effectively with diverse team members. Ability to formulate recommendations to improve quality and service delivery, and develop effective system and process improvements. Ability to multi-task and streamline day-to-day operations. Strong interpersonal and organizational skills, with the ability to work independently within established guidelines.
Licenses/Certifications Required
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations, and work on-call.
This position requires handling various caseloads and flexibility to adapt to changing priorities including redistributed work assignments, team projects, and other priorities as assigned.
Salary Range Disclaimer:
The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including:Paid Time Off (PTO)Tuition ReimbursementRetirement PlansMedical, Dental and VisionWellness ProgramVolunteer Time Off (VTO)
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Salary Range:
$88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan, serving more than 2 million members in five health plans, ensuring our members get the right care at the right place at the right time.
Mission:
L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Job Summary
The Customer Solution Center (CSC) Audit Readiness Specialist II is responsible for the execution, oversight, and monitoring of the guidelines and protocols to ensure readiness for all regulatory audits. This position will develop, with the assistance of CSC management, a successful auditing strategy for various end-to-end processes within CSC, including enrollment processing timeliness and accuracy, I.D. card issuance, outbound health risk assessment calls, call documentation, service authorization requests, and appeals and grievances across all lines of business. This position is responsible for the ongoing progression and maintenance of CSC's compliance program efforts, including policy and procedure development, training and education initiatives, and compliance programmatic enhancements.
This position will complete targeted, focused, and random audits related to member interactions and outcomes to ensure compliance. Results will be provided to management with recommendations and/or corrective actions required to remediate deficiencies. The position will lead all audit situations, present findings, and ensure action plans are created, executed, and verified through reconciliation of end-to-end regulatory functions.
Duties
Audit readiness:
Performs audit procedures for Customer Solution Center departments to ensure readiness; including identifying and defining issues, developing criteria, reviewing and analyzing evidence, and documenting business unit processes and procedures. Conducts interviews, reviews documents, develops and administers surveys, composes summary memos, and prepares working papers. Identifies, develops, and documents audit issues and recommendations using independent judgment concerning areas being reviewed. Communicates or assists in communicating the results of audit and consulting projects via written reports and oral presentations to management. Collaborates with business units in audit universe preparation and validation. Assists in document preparation for regulatory and internal audits.Regulatory compliance:
Works closely with Customer Solution Center Management to determine and handle effectiveness/accuracy of operational processes. Collaborates with internal Subject Matter Experts (SMEs) to understand regulatory processes and assists with identifying root causes of deficiencies. Evaluates policies and procedures with applicable regulations/guidelines and provides recommendations for continuous process improvements.Collaborates with Customer Solution Center Business Analyst to track, trend, and analyze results of Quality Assurance (QA) scorecards for training and quality improvement.Performs other duties as assigned.
Education Required
Bachelor's Degree. In lieu of degree, equivalent education and/or experience may be considered.
Experience
Required:A minimum of 5 years of experience in regulatory auditing in a healthcare environment required. Previous experience with Medi-Cal and Medicare in a managed care environment.
Preferred:Tableau experience.
Skills
Required:Advanced computer proficiency in Word, Excel, and Access. Strong analytical and team-building skills. Ability to work effectively with diverse team members. Ability to formulate recommendations to improve quality and service delivery, and develop effective system and process improvements. Ability to multi-task and streamline day-to-day operations. Strong interpersonal and organizational skills, with the ability to work independently within established guidelines.
Licenses/Certifications Required
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations, and work on-call.
This position requires handling various caseloads and flexibility to adapt to changing priorities including redistributed work assignments, team projects, and other priorities as assigned.
Salary Range Disclaimer:
The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including:Paid Time Off (PTO)Tuition ReimbursementRetirement PlansMedical, Dental and VisionWellness ProgramVolunteer Time Off (VTO)
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