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    Senior Compliance Auditor - Wilmington, United States - Jefferson Health Plans

    Jefferson Health Plans
    Jefferson Health Plans Wilmington, United States

    1 month ago

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    Description
    Why Choose Jefferson Health Plans?

    We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children's Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members.

    We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

    While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

    Perks of JHP and why you will love it here:
    Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing
    Flextime and Work-at-Home Options
    Benefits & Wellness Program including generous Time Off
    Impact on the communities we service
    We are seeking a talented and enthusiastic Compliance Auditor II to join our team

    The Compliance Auditor II is responsible for ensuring successful completion of assigned audit engagements set forth in the company's Audit Work Plan or by external regulators.

    The Auditor will manage and carry out non-clinical audit activities as assigned by the Compliance Auditing Manager.

    This position is responsible for applying regulatory compliance expertise and experience to examine documentation, interview employees, conduct analysis of the data to identify if deficiencies exist in meeting regulatory requirements.

    Apply best practices in controls and compliance with the requirements as well as any other relevant agency and/or organizational policies and procedures.

    As the Compliance Auditor II, your daily duties may include:
    Audit operational areas and delegated vendors for compliance and ensure Jefferson Health Plans (JHP) is meeting applicable federal and state laws and regulations, and contractual requirements as set forth by all regulatory entities including but not limited to Pennsylvania State regulatory agencies (DHS, DOH and PID) and Centers for Medicare and Medicaid (CMS)

    Act as liaison between Compliance and operational areas and delegated vendors to conduct internal audits and monitor improvement action plans.

    Act as the subject matter expert by performing non-clinical audits and collaborate on clinical audit activities with Clinical Compliance Auditors, when applicable.

    Lead and prepares the company for external audits, on-sites or imposed corrective actions performed by a regulator or agency acting on behalf of the regulator.

    Act as the subject matter expert by managing the audit and coordinating the external requests and internal activities. Ensures timely submission of deliverables and track noncompliance activities or issues reported or disclosed to the regulator or agency.

    Act as liaison between Jefferson Health Plans and the regulator or agency for all regulatory compliance external audits and any imposed corrective actions, sanctions or settlements.

    Participate and collaborate on clinical audit activities with Clinical Compliance Auditors, when applicable.
    Manage and monitor regulatory sanctions or penalties imposed by the regulator or agency.

    Work in collaboration with the business units, Compliance Audit Manager, Associate Compliance Officer, Compliance Officer, Legal and/or Finance to ensure sanctions or settlements have been processed and paid timely to the regulator or agency.

    Identify and communicate points of responsibility and accountability and make recommendations to develop and improve processes within JHP.
    Ensure all audit findings, corrective actions and risk issues are properly documented in the audit record. Ensure Compliance Audit Manager is kept abreast of all issues impacting the audit plan and audit area.
    Develop and implement audit tools in conjunction with, regulatory and sub regulatory guidance.
    Develop and implement strategies to address areas of non-compliance.
    Produce written status report on compliance activities on a regular basis and status meetings with Compliance Audit Manager as requested
    Establish and manage communication and escalation methods, establish and audit reporting timetable, issue/resolution process, and requirement prioritization process.

    Attend both internal and external meetings as directed by Compliance Audit Manager to ensure we are meeting the goals of the Compliance Department.

    Develop, implement and monitor audits and corrective action plans to ensure they are on track for completion and identify areas of weakness/potential liabilities.

    Write recommendations and document follow-up education on issues discussed by various committees.

    Organize and participate on internal workgroups to resolve operational issues and regulatory activities related to plan initiatives and/or regulatory and contract changes.

    Research business implications of regulatory specific requirements and manage issue resolution/triage process.
    Ensure Risk and Regulatory Compliance areas are made aware of noncompliance audit issues, findings, and corrective actions.
    Maintain appropriate record keeping and retention of all audits and monitoring of corrective actions data collected.
    Duties also include conducting compliance college presentations to educate employees on compliance audits and risks.
    Schedule and conduct meetings and create file notes/minutes for meetings attended.
    Qualifications
    Bachelor's Degree required. Master's Degree preferred.
    Possess relevant health care industry-specific certifications, such as Certified Healthcare Auditor (CHA), Certified Healthcare Compliance (CHC), Certified Public Accountant (CPA), and Certified Internal Auditor (CIA) or other relevant certifications preferred
    3+ years' managed care experience in health care compliance preferred
    2+ years' compliance, operational or vendor-related audit experience required
    Experience in working in a multifaceted health care environment, auditing, and monitoring corrective action plans with a clear understanding of the associated Federal and State rules, regulations, and contractual requirements preferred

    Skills, We Value:
    Knowledge of Federal and State requirements and the ability to analyze and interpret preferred
    Ability to utilize various remote working platforms (i.e., Microsoft Teams, Zoom, etc.) required
    Ability to maintain confidentiality of audit findings, recommendations and penalties/sanctions required
    Ability to apply audit standards through practical application required
    Ability to observe and understand multiple business processes and identify risk and opportunities required
    Aptitude to research, analyze and successfully resolve a broad spectrum of issues required
    Ability to handle multiple responsibilities and changing priorities required
    Ability to work with minimal supervision and great attention to details required
    Strong interpersonal and customer service skills required
    Outstanding written, oral and presentation skills as well as the ability to effectively deal with all levels of management required
    Ability to quickly learn and implement knowledge of new technical processes required
    Advanced computer skills and proficiency in Microsoft Office Suite (i.e., MS Word, Excel, PowerPoint, etc.) required
    Knowledge of medical terminology and claims coding preferred

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