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Health Plan Compliance Audit Lead

MemorialCare Health System Fountain Valley Full-Time
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Description

Purpose Statement/ Position Summary

The Compliance Auditor Lead provides assistance to the ClaimsCompliance Manager and compliance team in training, developing, and overseeingclaims research analysts and claims assistants in the coordination and deliveryof health plan and regulatory audit functions.  The Claim ComplianceLead is responsible for conducting research as it relates to health plan andstate/federal audits including claim findings, validation of regulations.

 
Essential Functions and Responsibilities of the Job
  • Monitors and assists the Compliance team and provides first line support for any compliance related questions/issues.
  • Works with manager to develop compliance team and monitor production.
  • Liaison between Claims department and health plans in the coordination of all health plan and state/federal audits.
  • Audits compliance reporting and ensure reports are submitted timely
  • Keeps up-to-date of all associated state/federal regulations and guidelines, and changes that effect the claims operations.
  • Documents claims processes and procedures.
  • Completes corrective action plans, ensures completion of health plan deliverables, and policy & procedures for health plan audits.
  • Assist the manager to conduct periodic internal reviews to ensure that compliance procedures are followed
  • Identify compliance issues that require follow-up or investigation.
  • Backs up and performs duties of positions in staff absence
  • Be at work and be on time.
  • Follow company policies, procedures and directives.
  • Interact in a positive and constructive manner.
  • Prioritizes and multitasks work assignments.
  • Complete any/all assignments and tasks assigned by the supervisor/manager.

Qualifications

Experience

  • 3 years’ experience of claims processing in a HMO environment
  • 1 year experience with local and federal medical claims regulations


Education

  • High School Diploma or G.E.D. preferred
  • Some college in business or health care preferred


Job: United States-California-Fountain Valley
Primary Location:
Schedule: Full-time
Shift: Regular
Job Posting:
 

Recommended skills

Auditing
Corrective And Preventive Actions
Investigation
Health Care
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Job ID: MEM003494

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MemorialCare Health System is a nonprofit integrated delivery system that includes five top hospitals – Long Beach Memorial, Miller Children's & Women's Hospital Long Beach, Community Hospital Long Beach, Orange Coast Memorial, and Saddleback Memorial; medical groups – MemorialCare Medical Group and Greater Newport Physicians; a health plan – Seaside Health Plan; and numerous outpatient health centers, imaging centers and surgery centers throughout the Southland (Orange County and Los Angeles County).

An innovator in health care delivery, MemorialCare focuses on evidence-based, best practice medicine. Our physicians and health care professionals study health care’s best practices and work to implement them at all our medical centers. The results are outcomes that frequently exceed state and national averages.

MemorialCare has gained widespread recognition for our unique approach to health care. In 2012 the organization was identified as one of the top 100 integrated healthcare networks nationwide and top 10 in the west region by IMS.

MemorialCare Health System owns a strategic investment company MemorialCare Innovation Fund.

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