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Department(s): Audit & Oversight
Reports to: Manager, Audit & Oversight
FLSA status: Non-Exempt
Salary Grade: I - $61,000 - $85,000
The Audit & Oversight Auditor will conduct routine oversight, monitoring, and auditing of all internal business functions within CalOptima, as well as externally delegated functions such as Claims, Customer Service, and Credentialing to ensure compliance with state, federal, and accreditation standards.
• Informs various departments within CalOptima, and delegates of CalOptima, of any changes to regulatory requirements.
• Assists in the development of audit tools and issues corrective action plans to address any identified issues.
• Facilitates mock audits of department functions using audit tools and develops corrective action plans to address any identified issues.
• Conducts validation audit for applicable areas of identified deficiencies to ensure all remediation efforts are effective and sustained.
• Conducts pre-delegation audit for applicable areas to ensure that vendor can perform the delegated activities prior to delegation.
• Conducts annual audits for applicable areas for existing delegated entities and ensures that vendors continue to perform the delegated activities in accordance with the agreement.
• Participates in workgroups that address both clinical and non-clinical activities for which CalOptima must demonstrate improvement to meet its contractual requirements with the Center for Medicare and Medicaid (CMS), California Department of Health Services (DHS), California Managed Risk Medical Insurance Board (MRMIB), Department of Managed Health Care (DMHC), and any other applicable entity.
• Serves as knowledge expert for assigned functional areas.
• Participates in the Audit and Oversight Committee meetings.
• Acts as a liaison with other areas and business units.
• Other projects and duties as assigned.
Possesses the Ability To:
• Demonstrate and motivate others in effective team coordination and cooperation.
• Establish and maintain effective working relationships with all levels of staff, other programs, agencies, and the general public.
• Communicate clearly and concisely, both verbally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience & Education:
• Bachelor's degree in a Health Care field or related field, or equivalent combination of education and/or experience as an Auditor required.
• 2+ years experience within a managed care plan and quality management required.
• 2+ years audit experience in Claims, Customer Service, Credentialing, or applicable area required.
• Valid driver's license and vehicle, or other approved means of transportation, an acceptable driving record, and current auto insurance will be required for work away from the primary office 35% of the time or more.
• Strong knowledge of managed care compliance for Medi-Cal, Dual Eligible Special Needs Plan (D-SNP), and Medicare-Medicaid Plan (MMP) plans.
• Fundamental principles of writing and grammar, including proper report and correspondence format, correct spelling and proper word usage, grammar, punctuation, and sentence structure.
CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.
Job Location: Orange, California
To apply, visit https://apptrkr.com/2342439
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