Compliance Advisor - Internal Auditor

Job type:
Start date:
Published at:
flag_no USA
Project ID:

This project has been archived and is not accepting more applications.
Browse open projects on our job board.
  • The Compliance Advisor ensures that internal departments are compliant with all State Programs product lines program contractual, state and federal regulatory requirements.
  • Participate in annual internal audits.
  • Work with internal staff to correct performance deficiencies.
  • Identify internal areas for improvement.
  • Serve as the compliance contact with internal departments for member grievance oversight, pharmacy, provider network, and member services for all State Program product lines.
  • Provide regulatory guidance, legislation analysis, and interpret product line program requirements for the company and its contracted entities.
  • Act as a resource to internal staff on all product line compliance and regulatory matters.
  • Perform ad hoc internal audits as required.
  • Conduct oversight to correct performance deficiencies.
  • Monitor member grievances and adherence to the claims compliance standards for timeliness & appropriateness.

  • High School Diploma Required.
  • Bachelor's degree in Business or Health Care Management.
  • In lieu of a Bachelor's degree, at least 6 years progressive managed care, healthcare, healthcare compliance, and/or work experience will be considered.
  • Master's degree in Public Health or Health Care Management or other related area preferred.
  • At least four years in a managed care setting required.
Required Skills:
  • Experience in health care auditing and monitoring (preferable in Appeals, Grievances, Quality Improvement, UM and so forth) and developing audit tools.
  • Knowledge in health care compliance.
  • Ability to manage multiple priorities and projects and meet deadlines.
  • Demonstrated experience developing and delivering training programs and making presentations.
  • Knowledge of Managed Care principles and/or government programs.
  • Working knowledge of DHCS, DMHC and CMS regulatory requirements.
  • Highly developed analytical and critical thinking skills.
  • Excellent written and oral communication skills are essential.
Preferred Skills:
  • 2 years Medi-Cal and Medicare compliance, or provider series/contracting experience.
  • One year staff training experience.