Compliance Auditor

Community Health Plan of Imperial Valley•Imperial, CA

1d•$80,000 - $100,000

About The Position

The Compliance Auditor plays a critical role in advancing the mission of Community Health Plan of Imperial Valley (CHPIV) by ensuring that administrative/non-clinical functions performed by delegated entities are in full compliance with regulatory, contractual, and clinical standards. Our new Compliance Auditor will evaluate process compliance and operational workflows for internal and delegated functions, identify systemic issues and contribute to corrective action planning, monitor regulatory metrics and reporting to committees, and conduct audits of non-clinical delegated functions including claims, encounters, credentialing, language assistance services, and program effectiveness. The role involves reviewing and validating the accuracy, completeness, and timeliness of delegate-submitted reports, logs, and materials, and assessing compliance with DHCS, DMHC, CMS, and NCQA regulatory requirements, as well as contractual obligations. The Compliance Auditor will identify gaps in documentation, workflows, and performance that could result in audit findings or compliance risks, monitor corrective action plans and validate the resolution of findings to ensure sustained compliance, and support enterprise-wide verification studies and external audit readiness, including pre-audit documentation review and file validation. Collaboration with internal departments and external delegates is key to ensure alignment and operational consistency.

Requirements

Bachelor’s degree in Healthcare Administration, Public Health, Business, or a related field; equivalent experience may be considered in lieu of degree
Minimum of 3-4 years of experience in compliance, auditing, or regulatory oversight within a managed care or healthcare delivery environment.
Familiarity with Medi-Cal and/or Medicare regulatory requirements (DHCS, DMHC, CMS).
Strong understanding of delegated functions such as claims, encounters, credentialing, and language assistance services.
Demonstrated ability to review and interpret policies, procedures, and operational workflows.
Excellent organizational, analytical, and time management skills with the ability to manage multiple priorities.
Strong written and verbal communication skills, including the ability to draft audit findings and compliance reports.
Proficiency in Microsoft Office (Excel, Word, Outlook, PowerPoint) and experience working with audit tracking systems or similar tools.
Ability to work independently and collaboratively in a fast-paced, deadline-driven environment.

Responsibilities

Evaluate process compliance and operational workflows for internal and delegated functions.
Identify systemic issues and contribute to corrective action planning.
Monitor regulatory metrics and reporting to committees.
Conduct audits of non-clinical delegated functions including claims, encounters, credentialing, language assistance services, and program effectiveness.
Review and validate the accuracy, completeness, and timeliness of delegate-submitted reports, logs, and materials.
Assess compliance with DHCS, DMHC, CMS, and NCQA regulatory requirements, as well as contractual obligations.
Identify gaps in documentation, workflows, and performance that could result in audit findings or compliance risks.
Monitor corrective action plans and validate the resolution of findings to ensure sustained compliance.
Support enterprise-wide verification studies and external audit readiness, including pre-audit documentation review and file validation.
Collaborate with internal departments and external delegates to ensure alignment and operational consistency.