Managed Care Auditor Jobs in Riverside, CA (NOW HIRING)

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

The Compliance Auditor II conducts comprehensive audits and reviews across the Plan, including assigned areas and Plan delegates, to ensure adherence to Federal, State, and contractual regulatory requirements. Identifies and assesses risks impacting overall compliance, drafts detailed audit findings and actionable recommendations, and evaluates operations, policies, and processes throughout the Plan. Conducts evaluations of operations, policies, and processes to validate compliance, evaluate effectiveness, and identify issues. Issues corrective action plans and reviews for acceptance to ensure that all compliance issues are appropriately addressed. Performs validation audits to determine if actions have been taken to mitigate identified risks and conducts routine monitoring across the Plan to address compliance concerns and emerging risks. Participates in special reviews as necessary.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

1. Conduct audits and testing procedures of assigned areas and Plan delegates, including detailed testing activities, documenting findings in audit work papers, developing detailed document requests lists, conducting walk-throughs, and proposing recommendations for improvement.
2. Develop and maintain audit tools based on regulatory compliance with DHCS, DMHC, and CMS requirements.
3. Document audit conclusions that are based on a complete understanding of the process, circumstances, and risk.
4. Perform validation audits to determine if actions have been taken to mitigate risks identified.
5. Support the development and acceptance of corrective action plans (CAPs) from internal departments and delegates to ensure accuracy and regulatory adherence.
6. Validate corrective action plans (CAPs) from internal departments and delegates to ensure appropriate completion and make necessary recommendations as needed for compliance.
7. Perform evaluations of operations, policies, and processes to validate compliance, evaluate effectiveness, and identify issues.
8. Support the identification of and communicates issues raised, offering recommended solutions relevant to business and risk.
9. Conduct regulatory research and provides interpretation of regulations to ensure appropriate application.
10. Support the maintenance of risks for assigned areas in the Compliance Risk Universe to ensure risk mitigations plans are developed and risks assessed and refreshed as needed.
11. Support the development of risk assessments to identify compliance risks posed to the Plan.
12. Conduct routine monitoring activities to ensure compliance with regulatory and contractual requirements.
13. Assist with reports for presentation to the Executive Compliance Committee and the IEHP Governing Board.
14. Conduct compliance assessments as needed.
15. Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Education & Requirements 

• Minimum or five (5) or more years in managed care operations requierd, working with one or more of the following areas: Utilization Management, Claims, Pharmacy Operations, Compliance, Delegation Oversight, Quality Management, Care Management, and/or Grievances and Appeals
• Demonstrated experience, at a professional level, in an audit role
• Experience with interpretation and/or implementation of California managed care regulations
• Two (2) years of audit or quality assurance/quality improvement experience required
• Bachelor’s degree from an accredited institution required
  • In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position
  • This experience is in addition to the minimum years listed in the Experience Requirements above
• Certified Internal Auditor (CIA), Certified Health Care Compliance (CHC), Certified Healthcare Auditor (CHA), and/or CHIAP (Certified Healthcare Internal Audit Professional) preferred

Key Qualifications

• Demonstrated understanding of audit standards and requirements, statistical data interpretation and applicability, risk assessment and control environments, audit theory and processes, and of the professional practice standards of internal auditing
• Demonstrated current knowledge of business ethics and compliance risks and the knowledge to assist with management of those risks in a dynamic health care environment
• Proficient knowledge of CMS Program Audit Protocols, DHCS Technical Assistance Guides, and DMHC Technical Assistance Guides
• Knowledge of regulatory research and regulations that apply to California Managed Care Health Plans
• Possess strong written and verbal communication skills, including a strong business writing aptitude
• Possess strong problem solving and creative thinking skills and the ability to reprioritize workload as needed
• Must be detail oriented, self-directed, and work with minimal supervision, both independently and in teams
• Requires well-developed skills in problem identification, analysis, resolution, organization, prioritization, timeliness, and attention to detail
• Proficient in Microsoft applications (Word, Excel, PowerPoint, Outlook, etc.). Advanced skills in MS Excel preferred
• Effective in a consulting role with the ability to become a trusted advisor
• Ability to maintain excellent interpersonal relationships within the department and at all levels of the organization
• Ability to organize thoughts and data into well-organized communications and reports

Start your journey towards a thriving future with IEHP and apply TODAY!

This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA.)