265 REGULATORY COMPLIANCE-Compliance Auditor-Internal Audit, Special Investigations Unit and Fraud, Waste & Abuse
Company: Alameda Alliance For Health
Posted on: June 6, 2021
At Alameda Alliance for Health (Alliance) we are striving each
day to create a healthier community and to improve the quality of
life of our members throughout our diverse County. As a part of our
mission, we collaborate with our provider partners to address
social determinants of health and to deliver high quality,
accessible, and affordable health care services.
Under the general direction of the Manager, Compliance Audits
and Investigations, this position is responsible for supporting the
Alameda Alliance for Health's Compliance Program, with an emphasis
on Special Investigation Unit (SIU) and Fraud, Waste and Abuse
(FWA) auditing activities.
PRINCIPAL RESPONSBILITIES INCLUDE:
- Lead and coordinate audits of providers to ensure compliance
with regulatory and contractual requirements.
- Collaborate with FWA vendor to investigate routine allegations
of suspected FWA; including research, evidence gathering,
interviewing, document review and data analysis.
- Schedule and conduct regularly scheduled and ad-hoc audits of
Alliance and Alliance providers to ensure compliance with
regulations and controls by examining and analyzing records,
reports, operating practices and documentation.
- Develop and update audit tools to account for current
- Create and Implement the development of and the monitoring of
corrective action plans resulting from audits to mitigate
- Recommend opportunities to strengthen the internal
- Develop, plan and coordinate preparatory "mock" audits,
including reviews of policies & procedures, DMHC & DHCS technical
assistance guides (TAGs), conduct question and answer sessions, and
lead departments through audit prepatory measures as needed.
- Assist in management of the AAH audit calendar.
- Present FWA audit findings to the Alliance Compliance Committee
for review, discussion, and approval at least quarterly, or sooner
- Assist in the development of Alliance's policies and procedures
and monitoring of the annual policy review process.
- Train and assist various departments in developing best
practices in their operations in accordance with established
policies and procedures.
- Assist in reviewing policies for updating to include regulatory
- Maintain a strong working knowledge of FWA related state and
federal legislation, statutes and regulations, and local, state,
and national health issues affecting publicly-funded managed care
organizations and the Alliance.
- Maintain knowledge of business products and related Alliance
policies and procedures.
- Research and interpret Knox-Keene Act, Title 22 and Department
of Health Care Services (DHCS) regulations.
- Monitor regulatory/compliance climate and escalate issues when
- Complete other special projects and duties as assigned.
ESSENTIAL FUNCTIONS OF THE JOB:
- Audit various types of provider specialties.
- Establish a strong working relationship with AAH FWA
- Interpret and understand detailed data queries.
- Develop and update internal audit tools, destop
procedures/workflows, reports, and criteria metrics, as
- Research, interpret, and provide analysis of state and federal
legislation, statutes and regulations as applicable to company FWA
related policies and procedures.
- Communicate effectively and efficiently internally and
- Comply with, and support the organization's compliance with,
the organization's Code of Conduct, all regulatory and contractual
requirements, organizational policies, procedures, and internal
- Constant and close visual work at desk or computer.
- Constant sitting and working at desk.
- Constant data entry using keyboard and/or mouse.
- Frequent verbal and written communication with staff and other
business associates by telephone, correspondence, or in
- Frequent lifting of folders and other objects weighing between
0 and 30 lbs.
- Frequent walking and standing.
- Occasional driving of automobiles.
NUMBER OF EMPLOYEES SUPERVISED: 0
EDUCATION OR TRAINING EQUIVALENT TO:
- Bachelors of Arts or Bachelors of Science degree required.
- Familiarity with Medicaid (Medi-Cal), Knox-Keene Act, and other
publicly funded programs preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
- Two years of experience in health care, auditing, compliance,
regulatory, FWA investigation, and/or insurance/managed care
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
- Exemplary interpersonal skills, including ability to work
effectively as part of a team across organizational structure.
- Ability to analyze and interpret legislative, statutory,
regulatory, and legal language.
- Experience in fraud, waste and abuse investigations, medical
billing, pharmacy claims, or claims processing preferred.
- Strong analytical problem-solving skills with initiative.
- Ability to work independently is critical.
- Strong organizational/documentation skills.
- Strong project management experience preferred.
- Ability to meet deadlines and adjust to changes in policies,
procedures, and priorities.
- Effective verbal and written communications skills.
- Ability and willingness to take initiative to address problems
and make continuous process improvements.
- Ability to enforce and educate staff in Compliance areas,
including established ethics and codes of conduct.
- Ability to interface with senior management and translate
complex issues into project plans with deliverables and measurable
- Proficient experience/comfort in use of computer software.
Microsoft Word, Excel, Outlook, and PowerPoint as well as internet
search skills mandatory.
Salary Range: $58,760 - $88,150
Alameda Alliance for Health is an EQUAL OPPORTUNITY EMPLOYER.
Applicants and employees are considered for positions and are
evaluated without regard to mental or physical disability, race,
color, religion, gender, national origin, age, genetic information,
military or veteran status, sexual orientation, marital status or
any other protected Federal, State/Province or Local status
unrelated to the performance of the work involved.
- 1240 S Loop Rd, Alameda, CA 94502, USA
Keywords: Alameda Alliance For Health, Alameda , 265 REGULATORY COMPLIANCE-Compliance Auditor-Internal Audit, Special Investigations Unit and Fraud, Waste & Abuse, Other , Alameda, California
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