Job DetailsJob LocationMain Office - Santa Barbara, CAPosition TypeFull TimeJob CategoryComplianceDescriptionCalifornia Salary Range:$82,165 - $119,140Job SummaryUnder the direction and supervision of the Audit Manager within the Audits, Monitoring, & Oversight Department of the Compliance Division, and through collaboration with Directors and Management level staff, this position conducts audit activities of varying complexity and supports initiatives of moderate to complex difficulty related to CenCal Health's audits, monitoring, and oversight program. This includes the performance of routine and complex audit, monitoring, and oversight activities of internal departments and external partners to ensure compliance with State and Federal regulatory and contractual requirements, and operational plan requirements, as well as assisting in writing, reviewing, and coordinating remediation and corrective action plans.Duties & ResponsibilitiesUsing clinical experience and expertise, conduct routine and complex compliance audit activities (e.g., reviewing of medical records) of internal departments and external partners, documenting results in audit work papers, developing detailed document request lists, conducting audit conferences and walk-throughs, and proposing recommendations for improvement.Review documented clinical processes against contractual, Federal, and State requirements, as well as NCQA standards.Conduct regulatory research to identify gaps and provide an interpretation of clinical requirements and regulations to ensure appropriate application of medical and clinical criteria.Develop audit scope and maintain audit tools based on regulatory compliance with DHCS, DMHC, and CMS requirements, as well as NCQA standards.Able to write clear and concise audit reports based on audit results, ensuring accuracy and quality of audit reporting and utilizing clinical knowledge to determine findings.Assist in development and implementation of quality improvement, remediation plans (RPs), and corrective action plans (CAPs) based on risk analysis, audit findings, or delegate performance, to ensure evidence of corrective actions is in place.Assist in the maintenance of CenCal Health's risk logs and audit tools.Using clinical experience and expertise, conduct routine monitoring activities to ensure compliance with regulatory and contractual requirements.Create reports and analyze data for reporting to management, the Delegation Oversight Committee, Compliance Committee, and Board of Directors.Prepare and send out audit announcement memos.Prepare audit programs and conduct audits of assigned areas, including performing various audit procedures and documenting audit findings.Perform and coordinate follow-up audits to determine if management has taken action to mitigate the risks identified.Provide independent evaluations and assist with the maintenance of operational controls, tools, policies, and procedures.Assist and support the development of materials for audit Entrance and Exit conferences.Train internal audit participants/ business owners on audit process and/or tools.Comply with HIPAA, Privacy, and Confidentiality laws and regulations.Other duties as assigned.QualificationsKnowledge/Skills/AbilitiesRequired:Audit experience with DHCS, CMS, DMHC, and/or NCQA and an understanding of clinical audit standards and requirements;Excellent written and verbal communication skills with strong business writing aptitude;Experience researching, compiling, and organizing information from various sources;Strong organizational skills and attention to detail;Strong skills in problem identification, analysis, resolution, organization, and prioritization;Demonstrate ability to accurately apply and interpret clinical guidelines;Ability to reprioritize workload as needed;Ability to work productively with all Plan staff;Ability to coordinate work between departments;Ability to work with minimal supervision, both independently and in teams;Attention to detail and accuracy.Desired:Certified Internal Auditor (CIA), Certified Health Care Compliance (CHC), Certified Healthcare Auditor (CHA), CHIAP (Certified Healthcare Internal Audit Professional) preferred or ability to achieve certification within 1 year.Experience in health care compliance.Education & ExperienceAdvanced degree, Bachelor's preferred or equivalent experience in clinical field.Current active, unrestricted, California Registered Nurse (RN) and/or Nurse Practitioner (NP) License.2 years of (a)combined clinical and compliance experience or (b) auditing experience in a healthcare environment.#J-18808-Ljbffr

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