Job: Compliance Auditor

This position supports the Compliance Department by providing auditing and monitoring activities for Medicare, Medicaid, Long-Term Care division, and Commercial lines-of-business.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.

Annual development and approved by CO, CC, & BOD of auditing programs specific to

Medicare, Medicaid, Long-Term Care division, and Commercial Lines-of-business.

Implementation of approved auditing program according to scheduled calendar, analyses of results, and reporting to CCO and CC.

Identification of outlines and trends with recommendations for corrective action plans as well as responsibility for monitoring and reporting in CAPS.

Development of monitoring activities including reports from plan database as well as analyses of existing reports from regulatory agencies, regarding Part D Reporting, CMS subcontract

Work with medical economics and quality improvement staff to identify areas for compliance monitoring and auditing.

Provide some validation activities for reports and data submissions to CMS and ACHA to ensure departments submitting data are knowledgeable regarding data requirements.

Work with the Part D Compliance Officer and Part D Manager to ensure receipt of regulatory reporting data and to develop auditing and monitoring activities in collaboration with the PBM.

Participate on the Fraud, Waste and Abuse data collection and analyses investigations and other work groups as requested by the Chief Compliance Officer.

QUALIFICATIONS to perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Proficient in PC skills.

Strong oral and written communication skills

Strong planning, problem solving, and change management skills.

Strong skills in personal diplomacy; demonstrate personal traits of a high level of motivation, team orientation, professionalism and trustworthiness, and places a high value on treating others with dignity and respect.

Demonstrate ability to deal with legal issues.
Proven ability to transfer knowledge.

EDUCATION and/or EXPERIENCE

Bachelors Degree or relevant experience

Business Systems knowledge

Excel spreadsheet experience required

Data Analyses

Working knowledge of the HMO industry particularly Medicare and/or Medicare Reporting

Claims background a plus

PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee frequently is required to walk and sit. The employee is occasionally required to stand and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.

WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.