265 REGULATORY COMPLIANCE-Compliance Auditor-Internal Audit, Special Investigations Unit and Fraud, Waste & Abuse

Company: Alameda Alliance For Health
Location: Alameda
Posted on: June 6, 2021

Job Description:

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 regulatory requirements.
• Create and Implement the development of and the monitoring of corrective action plans resulting from audits to mitigate risks.
• Recommend opportunities to strengthen the internal controls.
• 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 if necessary.
• 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 standards.
• 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 necessary.
• 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 vendor.
• Interpret and understand detailed data queries.
• Develop and update internal audit tools, destop procedures/workflows, reports, and criteria metrics, as needed.
• 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 externally.
• 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 controls.

PHYSICAL REQUIREMENTS:

• 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 person.
• 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

MINIMUM QUALIFICATIONS:

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 experience required.

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 outcomes.
• 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.

Other details

• Pay Type Salary

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• 1240 S Loop Rd, Alameda, CA 94502, USA

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