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    Compliance Audit Program Manager - San Jose, United States - Santaclara Family Health Plan

    Santaclara Family Health Plan
    Santaclara Family Health Plan San Jose, United States

    1 day ago

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    Description

    FLSA Status:
    Exempt


    Department:
    Compliance


    Reports To:
    Manager, Oversight


    GENERAL DESCRIPTION OF POSITION


    The Compliance Audit Program Manager is responsible for coordinating plan-wide auditing activities, including audits of the Plan's internal business units and First Tier, Downstream and Related entities (FDRs).

    The incumbent participates in the development of risk assessment tools and in conducting risk assessments for business units and FDRs, and develops a comprehensive audit plan tailored to address the relative risks presented by each business unit and FDR.

    The Compliance Audit Program Manager also develops compliance audit protocols, manages and conducts audits, drafts and presents audit reports and manages the corrective audit process to ensure proper remediation of deficiencies identified in audits.


    ESSENTIAL DUTIES AND RESPONSIBILITIES
    To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.


    • Develop and maintain Risk Assessment tool(s) and conduct and analyze results of Risk Assessments.
    • Establish an audit work plan and schedule based on results of Risk Assessment and other relevant inputs, including observed and reported non compliance, changes in law or regulation, and scope of delegated duties.
    • Organize, coordinate, conduct, and lead internal audits to evaluate the adequacy and effectiveness of internal and operation controls designed to ensure that processes and practices lead to appropriate execution of regulatory requirements and guidelines, including federal and state regulations.
    • Prepare audit reports that identify potential deficiencies, risks, and issues, ensuring audit work papers are complete and thorough.
    • Recommend corrective actions and conduct reassessments of performance once corrective actions have been implemented.
    • Participate in the development of the Compliance Department's long-term and short-term goals, objectives, plans, policies and procedures.
    • Maintain a high level of knowledge in current audit requirements and provide innovative and creative ideas to formulate new audit approaches.
    • Provide expertise and training to staff on the audit process.
    • Perform other related duties as required or assigned.
    REQUIREMENTS - Required (R) Desired (D)

    The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.


    • Bachelor's Degree in Health Care Administration, Business Administration, Communications or related field, or equivalent experience, training or coursework. (R)
    • Minimum two years auditing experience, preferably in a managed care or health care environment. (R)
    • Demonstrated current working knowledge of audit theories, standards, and techniques. (R)
    • Experience in managed care or in a health care setting requiring routine interaction with internal and external stakeholders. (R)
    • Experience with Medi-Cal or Medicare programs. (D)
    • Ability to gather and analyze data, organize and write reports and organize work efficiently. (R)
    • Strong project management skills. (R)
    • Ability to develop an advanced level of knowledge of those portions of the laws and regulations relevant to CMS, DMHC, DHCS. (R)
    • Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
    • Working knowledge and the ability to efficiently operate all applicable computer software including a working knowledge of computer applications such as Outlook, Word, Excel and PowerPoint. Ability to learn how to expertly use the Health Plan's core database software. (R)
    • Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
    • Excellent communications skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments and outside entities over the telephone, in person or in writing. (R)
    • Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
    • Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
    • Ability to maintain confidentiality. (R)
    • Ability to comply with all SCFHP policies and procedures. (R)
    • Ability to perform the job safely with respect to others, to property, and to individual safety. (R)

    PHYSICAL REQUIREMENTS

    • Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
    • Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
    • Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
    • Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
    • Hearing/

    Talking Requirements:
    ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)

    • Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

    ENVIRONMENTAL CONDITIONS
    General office conditions. May be exposed to moderate noise levels.
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