MANAGED CARE COMPLIANCE AND AUDIT LEAD

The Managed Care Compliance and Audit Lead plays a key role in ensuring compliance with managed care regulations and delegated functions. Reporting to the Managed Care Compliance and Audit Manager, this role works closely with the CAP Team and MSO staff to provide compliance guidance, monitor regulatory requirements, and support operational audits.

This position oversees both internal audits and external audit preparations for agencies like CMS, DHCS, DMHC, NCQA, and contracted health plans, developing internal auditing tools, and ensuring all operational policies align with federal, state, and accreditation standards. The Lead will also be responsible for reporting compliance status to leadership and contracted health plans while ensuring adherence to Medi-Cal, Medicare Managed Care, and other HMO regulations.

ESSENTIAL JOB FUNCTIONS:

Compliance & Regulatory Oversight:

• Monitor federal, state, and health plan regulatory updates, ensuring the MSO remains compliant.
• Serve as the point of contact for regulatory communications, including CMS, DHCS, and DMHC guidance, Managed Care Operations Memos, and All Plan Letters (APL).
• Track program implementation timelines and report progress, performance outcomes, and operational barriers to MSO leadership and contracting health plans.

Audit Preparation & Oversight:

• Lead internal audits to assess compliance in claims processing, provider credentialing, utilization management, network management, and case management.
• Develop and refine internal auditing tools to monitor accuracy, performance, and compliance.
• Conduct routine audits (weekly, monthly, quarterly) to ensure compliance with contractual obligations and regulatory requirements.
• Prepare MSO for external audits by compiling and submitting required operational analyses, audit questionnaires, policies, procedures, and supporting documents.
• Track and ensure timely resolution of audit findings, preventing repeat deficiencies.
• Oversee sub-delegation audits for MSO’s delegated groups and vendors, reporting results to relevant committees and ensuring remediation of non-compliance issues.

Quality Improvement & Corrective Action Plans (CAPs):

• Collaborate with various teams to develop, implement, and monitor Corrective Action Plans (CAPs) based on internal and external audit findings.
• Ensure continuous quality improvement by tracking compliance gaps, identifying trends, and recommending process enhancements.
• Work closely with leadership to design and refine operational workflows, policies, and procedures that align with best practices and regulatory requirements.
• Program & Process Development:
• Provide administrative support for CMS, DHCS, and contracted health plan programs, assisting in the development of program guides, workflow manuals, and data integration strategies.
• Participate in MSO program planning, system development, and process improvement initiatives to enhance efficiency and compliance.
• Identify systemic issues through internal reviews, complaints, or other mechanisms, implementing corrective measures to optimize operational effectiveness.
• Performs other job duties as required by manager/supervisor.

• Bachelor’s degree required.
• 5 years of experience in managed care required.
• Experience in compliance, operational auditing, or quality improvement preferred.
• Experience in a healthcare setting and knowledge of NCQA standards, Medi-Cal, and Medicare Managed Care regulations preferred.
• Strong understanding of managed care operations, including claims, provider credentialing, and utilization management.
• Excellent analytical, problem-solving, and communication skills.
• Ability to handle confidential information and collaborate across departments.
• Proficiency in Microsoft Office (Excel, Word, PowerPoint, Outlook).
• Ability to work with all levels of staff.

LANGUAGE:

• Must be able to fluently speak, read and write English.
• Fluent in Chinese (Cantonese and/or Mandarin) preferred
• Fluency in other languages are an asset.

STATUS:

• This is an FLSA Non-exempt position.
• This is not an OSHA high-risk position.

Salary : $46 - $53