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.
- 3 years’ experience of claims processing in a HMO environment
- 1 year experience with local and federal medical claims regulations
- High School Diploma or G.E.D. preferred
- Some college in business or health care preferred
United States-California-Fountain ValleyPrimary Location: Schedule:
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