Senior Health Plan Auditor

Job Summary

The Senior Health Plan Auditor is a hybrid role and is responsible all aspects of planning, execution, reporting and corrective action plans monitoring of  financial solvency and claims processing compliance for specialty health plans and vendors. These audits are intended to ensure that L.A. Care delegates are in compliance with regulatory requirements and L.A. Care contractual agreements across all lines of business.

The position is responsible for the DMHC claims data submissions for L.A. Care and its Plan Partners and delegates done each quarter and annually.

Primarily responsible for the creation, review, and submission of departmental policies and procedures annually.

Serves  as a subject matter expert and mentor for other staff.

Duties

• Performs financial audits and/or financial analyses for Specialty Health Plans.
• Performs financial analyses or vendor’s management for L.A. Care vendors.
• Performance claims audits for Specialty Health Plans and vendors.
• Provides timely and accurate deliverables to ensure financial solvency and claims processing compliance with regulatory and contractual requirements for plan partners, participating provider groups, capitated hospitals, specialty health plans, and vendors.
• Assists in the creation and implementation of standardized Specialty Health Plans’ and vendors’ workpaper and reporting templates.
• Responsible for the documentation and maintenance of Financial Compliance Department’s policies and procedures.
• Responsible for collection and completion of the quarterly and annual Department of Managed Health Care (DMHC)  filing submissions.
• Being cross trained on financial solvency reviews for PPGs, PPs, and capitated hospitals.
• Serves as primary contact and liaison for Centers for Medicare and Medicaid Services (CMS) claim audit section of L.A. Care delegates.
• Annually reviews and updates the department’s Policies and Procedures (P&Ps).  Ensures that any new or updated Policy and Procedure is reviewed and approved by management prior to submission.
• Accountable for the completion of requests from Legal Department, Delegation Oversight’s monitoring oversight and reporting.
• Serves as subject matter expert in assigned areas and cross training initiatives.
• Responsible for the overall communication and collaboration with interdepartmental personnel, leadership, specialty health plans, and vendors.
• Supports the design, implementation, and reporting of special projects.
• Supports the design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications.
• Supports the assessment, communication, implementation of regulatory requirements that may impact internal processes.
• Supports the formalization of key internal processes and monitoring tools with desktop procedures and applicable policies and procedures development.
• Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge.
• Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.
• Performs other duties as assigned.

Education Required

Experience

Required:

• At least 3 years of experience in conducting financial audits.  
• At least 5 years of related experience in the managed health care industry.  
• Minimum of 2 years of accounting experience.

Skills

Required:

• Strong analytical and critical thinking skills.
• Action-oriented, self-starter, and excellent motivator.
• Excellent verbal and written communication skills.
• Able to prioritize assignments, and able to independently with minimum supervision.
• Ability to interface professionally with both internal and external customers at all levels of the organization.
• Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint).

Licenses/Certifications (Must hold one of the below certifications):

Additional Information