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Position Summary

The Internal Audits Division Auditor conducts internal audits to monitor the adherence of various department processes to regulatory requirements. These departments include Utilization Management (UM), Case Management (CM), Member Services (MS), Pharmacy, Enhanced Care Management and Community Supports (ECM/CS), and Grievance and Appeals (G&A). The auditor evaluates compliance with established management control systems, policies, procedures, and regulatory standard requirements. They provide analysis, findings, results, and recommendations to the Internal Audits Division Manager. The auditors report directly to the Internal Audits Division Manager, who reports to the Chief Operations Officer (COO).

Compliance with Regulations

Works closely with all necessary departments or entities to verify that the processes, programs, and services are completed in a quality, timely, and efficient manner, in accordance with CHG policies and procedures, and in compliance with applicable state and federal regulations, contractual requirements, and accrediting bodies. The internal Audits Division team follows regulatory audit processes, including conducting exit interview meetings to present results and findings to the corresponding management team, issuing Corrective Action Plans (CAPs) as needed, and following up on CAPs. Uses NCQA's 8/30 model for sampling methodology.

Responsibilities

• Regulatory Knowledge: In-depth understanding or working knowledge of Department of Healthcare Services (DHCS), Centers for Medicare and Medicaid Services (CMS), and Department of Managed Healthcare (DMHC), and other regulatory agencies as it relates to regulatory requirements related to UM, CM, MS, Pharmacy, ECM/CS, and G&A.
• Departmental Policies: In-depth understanding of the policies and procedures, desktop processes, and best practice guides used by the UM, CM, MS, Pharmacy, ECM/CS, and G&A departments.
• Implements and maintains established audit/control systems to ensure policies and procedures are met.
• Documents and maintains records of all audits performed, including raw data or files reviewed, report of findings, corrective action plans, reassessment, and any ongoing monitoring logs.
• Investigates, reviews, and analyzes data related to UM, CM, MS, Pharmacy, ECM/CS, and G&A by applying knowledge of established policies and regulatory guidelines to improve department audit preparedness.
• Inputs audit data into an audit scoring tool, reports findings, and recommends corrective action.
• Reports any audit concerns to the supervisor without delay.
• Provides recommendations for staff training based on audit findings and potential risks.
• Reassesses a deficiency after a corrective action has been implemented and conducts ongoing monitoring to ensure that the deficiency does not reoccur.
• In concert with department management, assists in preparation of documents for any external or internal audits and accreditation surveys.
• Assists in the development of new audit methodology and scope on an as-needed basis.
• Stays up to date with all relevant changes to state and federal regulations, contractual requirements, and accreditation standards.
• Maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, and participating in professional societies.
• Contributes to the team effort by accomplishing related results as needed.
• Maintains company reputation and contributes to the team effort by conveying a professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.
• Performs other duties as assigned.

Education and Experience

• Bachelor’s degree in a healthcare-related field is required.
• Two or more years in a managed care setting, with at least one year of experience in an auditing role (preferably in the healthcare industry).
• Solid healthcare and managed care background with knowledge of Medi-Cal and Medicare guidelines.
• Proficiency in Microsoft Office: Word, Excel, PowerPoint, and Outlook. Knowledge of QNXT and related software applications; ability to navigate internal data and systems.
• Excellent verbal and written communication skills, strong analytical abilities, and interpersonal skills.
• Excellent organizational skills with the ability to handle multiple tasks and/or projects simultaneously, prioritize work effectively, and demonstrate superior attention to detail.
• Ability to handle confidential, sensitive information with professionalism.
• Ability to retrieve information from various sources, analyze it effectively, and apply mature, independent judgment.
• Strong agility and adaptability to changing regulations, timelines, and requirements.
• Problem-solving skills with the ability to look for root causes and implementable, workable solutions.
• Auditing of pharmacy department activities may require a Certified Pharmacy Technician with an Active California Pharmacy Technician license.

Physical Requirements

• Prolonged periods of sitting.
• Prolonged use of a computer.
• May be required to work evenings, weekends, and holidays.

The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified

All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.