This position will perform the following types of reviews and audits that would address the requirements and recent agreements between DMHC and the Plans. This would include system integrity audits, compliance program review, and for DHCS Newly Contracted Provider Training audits as well as oversight of internal controls – such as ownership, organizational structure, and other complex issues related to DMHC, DHCS, CMS and LA Care requirements. These positions will work closely with finance on reviews of systems and operations based upon repeated financial solvency CAPs as reported by the DMHC or as determined by Blue Shield of California’s review of the annual/quarterly financial statements.
- Responsible for performing regulatory/contractual delegation oversight control audits to ensure compliance with Federal and State regulatory agencies. Assures compliance to external specifications and standards. Conducts comprehensive regulatory reviews using a standard audit model.
- Provides highly complex analysis and defines efficiency in relation to compliance programs and internal controls.
- Coordinates the audit of compliance programs and internal controls with other internal and external audit teams.
- Provide administrative oversight of 3rd party relationships with performance/tracking systems.
- Participate in special projects as needed.
- Responsible for proactively improving upon existing processes and systems using significant conceptualizing, reasoning and interpretation.
- Works to influence others to accept audit results and accountability for audit results.
- Results may serve as precedent for future decisions.
- Problems and issues faced are numerous, and typically undefined where information is difficult to obtain.
- Conducts extensive investigation, critical thinking to understand root cause of problems. Problems span a wide range of difficult and unique issues across functions and/or businesses.
- Develops new perspectives and innovative approaches on existing or new problems.
- Applies agile methods.
- Communicates with parties within and outside of own job function.
- Has responsibilities for communicating with parties’ external to the organization, which may include customers or vendors.
- Works to influence others to accept job function’s view/practices, and agree to or accept new concepts, practices, and approaches.
- Requires ability to communicate with executive leadership regarding matters of significant importance to the organization.
- Generally, conducts briefings with senior leaders within the job function.
- Provide guidance and training externally to provider organizations.
- Responsible for managing large, complex project initiatives of strategic importance to the organization, involving large cross-functional teams.
- May direct the work of other individual contributors and/or act as a cross-functional team lead.
- Other duties as assigned.
Knowledge, Experience, and Education
- May require a bachelor's degree or equivalent and minimal to moderate experience in managed care setting, healthcare industry or related field.
- Extensive experience in health care specific to compliance-operations, privacy, audit and legal investigative services.
- Requires deep job knowledge and application typically obtained through advanced education combined with experience.
- Minimum of 10 years of prior relevant experience within a managed healthcare organization with an emphasis on compliance.
- Certification from HCCA or equivalent experience or training.