Job Description
The Managed Care Compliance Specialist is responsible for assisting with the implementation of the internal auditing and monitoring program within the Managed Care department by ensuring compliance with applicable rules and regulations, including but not limited to AB1455 and Medicare Claims Processing Guidelines. This position is responsible for maintaining routine auditing functions and providing feedback on departmental activities, to assure compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHCS.
Duties and Responsibilities:
• Ensures all services provided to Commercial, Medicare, and Medi-cal managed care members are in compliance with program regulations, insurance regulations, and regulatory requirements. • Maintains and tracks laws and regulations, contract documentations, amendments, and various compliance measures pertaining to Commercial, Medicare, and Medi-cal managed care. • Develops policies, procedures, and processes to align with federal program regulations and any applicable state regulations pertaining to Commercial, Medicare, and Medi-cal managed care. • Provides mentorship to various departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contract language for Commercial, Medicare, and Medi-cal managed care. • Acts as a liaison with health plans and current CSHS departments to ensure both health plan regulations and CSHS policies are met. • Coordinates and acts as primary contact for all health plans audits, including leading all aspects of the review for performance management and accurate coding. • Develops and supervises compliance with corrective action plans as a result of post-health plan audits and regulatory audits. • Provides required Compliance and FWA trainings for existing, new employees and non-employees, as the need arises. • Educates CSHS employees on company policies and procedures regarding access to care, the grievance and appeals process, the eligibility process, etc. • Remains updated on all member and provider policy changes made by the health plan and/or the State. • Acts as subject matter expert on health care laws/regulations as a compliance resource to CSHS and affiliates, including contracted and employed physician practices. • Aggregates, analyzes, and reports audit results, identifies error trends and root causes, and makes recommendations for performance improvements.
Qualifications
Education: High school diploma/GED required. Bachelors degree in Healthcare or related field preferred.
Experience: Five (5) years of compliance experience, preferably in a healthcare environment, required. Two (2) years of Medi-Cal, Medicare, or Commercial Managed Care experience preferred.
Cedars Sinai is one of the largest nonprofit academic medical centers in the United States, and it is the largest private academic medical center in the Western United States. The Cedars Sinai main campus, which encompasses nearly 24 acres, is located at the point where the cities of Los Angeles, Beverly Hills, and West Hollywood meet. Cedars Sinai has been recognized annually by U.S. News & World Report’s top 10 best hospitals in the U.S. The institution most recently placed No. 7 among a select group of 20 Honor Roll hospitals and ranked nationally in a dozen specialties. In addition, Cedars Sinai ranked No. 3 in California and No. 2 in the Los Angeles metro area.
Within Cedars Sinai, the Institute for Research on Health Aging conducts multi-disciplinary research that prioritizes the prevention of cardiovascular disease, neurocognitive disease, and cancer. Our focus is on translating new research discoveries into pragmatic interventions aimed at promoting healthy aging across diverse populations. Our approach involves human physiology, cohort, and clinical trial studies and our team includes established experts in population, clinical, translational, basic, and data science.