Compliance Auditor – Internal Audit/ Job Req 788805274 (Finance)

PRINCIPAL RESPONSIBILITIES:
Under the general direction of the Supervisor, Health Plan Investigations, this position is responsible for supporting the Alameda Alliance for Health's Compliance Program, with an emphasis on internal auditing activities.
Principal responsibilities include:
Lead and/or coordinate internal audits of Business Units to ensure compliance with regulatory and contractual requirements for all Alameda Alliance products and business.

Coordinate the scheduling of internal audits including those specific to Medicare Advantage and Part D requirements, aligning with the organization's enterprise risk management framework.
Conduct regularly scheduled and ad-hoc internal audits of Alliance departments to ensure compliance with regulations and controls by examining and analyzing records, reports, operating practices and documentation with a focus on Medicare, Medi-Cal and Commercial compliance functions, such as enrollment, appeals and grievances, formulary administration, and coverage determinations.
Develop and update audit tools to account for all current regulatory requirements, including CMS regulations for Medicare Advantage and Part D programs.
Develop and implement processes for monitoring corrective action plans resulting from internal audits to mitigate risks ensuring alignment with state and federal programs and the organization's risk appetite and tolerance levels.
Recommend opportunities to strengthen the internal controls and suggest risk mitigation strategies aligned with the organization's Enterprise Risk Management (ERM) framework.
Develop, plan and coordinate preparatory "mock" audits, including reviews of policies & procedures, DMHC & DHCS technical assistance guides (TAGs), CMS audit tools to conduct question and answer sessions, and lead departments through audit preparatory measures as needed.
Assist in the management of the AAH audit calendar.
Present audit findings to the Alliance Compliance Committee for review, discussion, and approval at least quarterly, or sooner if necessary.
Incorporate ERM principles in audit planning and execution.Assist in the development of Alliance's policies and procedures and monitoring of the annual policy review process ensuring alignment with all Alliance products and business and incorporating enterprise risk management principles.
Train and assist various departments in developing best practices in their operations in accordance with established policies and procedures.
Assist in reviewing policies to reflect
Current regulatory standards.

Maintain a strong working knowledge of state and federal legislation, statutes and regulations, and local, state, and national health issues affecting publicly-funded managed care organizations and the Alliance, including Medicare advantage and Part D Programs, and their potential impact on the risk profile..
Collaborate with the Enterprise Risk Management team to:

Contribute to the development and maintenance of the organization's risk register
Assist in conducting enterprise-wide risk assessments
Support the integration of compliance and internal audit activities with broader ERM initiatives
Help identify emerging risks and trends that may impact the organization
Assist in the design and implementation of the risk assessment program.
Perform risk assessments,
Analyze findings.
Create customized, detailed reports for Committees, Executive Team and Board of Governors.
Assist with Fraud, Waste and Abuse (FWA) and Discrimination cases if necessary.
Complete other special projects and duties as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

Audit various business/department processes.
Develop and update internal audit tools, reports, and criteria metrics as needed incorporating Medicare, Medi-Cal and Commercial compliance measures and enterprise risk management key performance indicators (KPIs).
Research, interpret, and provide analysis of state and federal legislation, statutes and regulations as applicable to company 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.

Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:

Bachelor of Arts or Bachelor of Science degree required.
In lieu of degree, equivalent education and/or experience may be considered
Familiarity with Medicaid (Medi-Cal), Knox-Keene Act, Medicare Advantage, Part D, and other publicly funded programs preferred.
Experience with enterprise risk management practices is a plus.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

Two years of experience in health care, auditing, compliance, regulatory, investigation, and/or insurance/managed care experience required.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

Knowledge of Medicare Advantage and Part D regulations, including 42 CFR Parts 422 and 423.
Familiarity with CMS program audit protocols and experience with Medicare compliance audits preferred.
Understanding of Medicare Star Ratings program and quality improvement initiatives.
Certified in Healthcare Compliance (CHC) or Certified in Healthcare Privacy Compliance (CHPC) certification preferred.
Experience with risk management software or GRC (Governance, Risk, and Compliance) tools is a plus.
Certified Risk Management Assurance (CRMA) or similar risk management certification is desirable.
Strong analytical skills with the ability to identify, assess, and prioritize risks across the organization.
Proficiency in risk assessment methodologies and risk management tools.
Ability to communicate complex risk concepts to diverse stakeholders, including executive leadership.
Strong organizational/documentation skills.
Ability to meet deadlines and adjust to changes in policies, procedures, and priorities.
Effective verbal and written communications skills.
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 are mandatory

SALARY RANGE $83,241.60 - $124,862.40 Annually
The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.