Delegation Oversight Compliance Auditor III

L.A. Care Health Plan•Los Angeles, CA

10d•$88,854 - $142,166

About The Position

The Delegation Oversight Compliance Auditor III is responsible for planning, coordination, and conducting comprehensive compliance audits and reviews to assess adherence to regulatory requirements, contractual obligations, and internal policies for L.A. Care subcontracted providers. Additionally, the Auditor III will provide updates and recommendations to Management on quality and delegation oversight responsibilities, participate in fraud, waste, and abuse investigations as applicable, and oversee pre-delegation and annual audits for new and existing delegated entities to drive continuous improvement and adherence to regulatory standards by ensuring delegates are compliant with regulatory requirements. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.

Requirements

At least 4 years of audit experience in compliance, delegation oversight, or audit within the healthcare industry.
Demonstrated experience developing and delivering training programs and making presentations to internal staff and providers.
Experience in health care service plans with significant delegation arrangements.
Experience working with Policies and Procedures.
Ability to manage multiple priorities, projects and meet deadlines.
Superior written and verbal communication skills.
Ability to draft policies and procedures.
Exceptional analytical and problem-solving skills, with a meticulous attention to detail.
Strong communication and collaboration abilities, with the capacity to engage effectively with stakeholders at all levels.
Ability to create a work environment that fosters team building and encourages a collaborative approach to achieving departmental and organizational goals.
Proficient in Microsoft Office, Excel, and PowerPoint.
In-depth knowledge of federal and state laws, Medicaid regulations, and healthcare compliance standards.

Nice To Haves

Certified HealthCare Compliance (CHC)

Responsibilities

Applies subject expertise in evaluating business operations and processes.
Identifies areas where technical solutions would improve business performance.
Consults across business operations, providing mentorship, and contributing specialized knowledge.
Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices.
Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.
Researches, analyzes, and interprets contractual, state, and federal regulatory, and accreditation requirements.
Stays abreast of changes in healthcare regulations, laws, and industry standards; analyzes regulatory developments and assesses their impact on the organization.
Updates existing audit tools and creates audit tools based on the regulatory requirements.
Assists management team with informing team of regulatory changes to ensure alignment with regulatory requirements and industry best practices.
Plans, coordinates, and conduct with other auditors and conducts comprehensive compliance audits and reviews to assess adherence to regulatory requirements, contractual obligations, and internal policies for L.A. Care subcontracted providers including, but not limited to, Participating Physician Groups, Plan Partners, and Specialty Health Plans/Vendors.
Independently conducts complex audits, including scoping, research, tool development, field work, reporting, and corrective action plan validation.
Identifies, documents, and trends audit issues and provides appropriate coaching and shares best practices with delegated entities to assist with performance improvement.
Investigates and escalates allegations of non-compliance, fraud, or misconduct; develops and implements corrective action plans to address identified issues and prevent recurrence.
Conducts risk assessments to identify compliance risks and develops strategies to mitigate risks and strengthens internal controls.
Alerts management of identified new or emerging compliance risks and makes recommendations on DOA’s audit plan or monitoring plan to other business unit.
Serves as a subject matter expert in compliance auditing, risk assessment, risk mitigation planning and regulatory interpretation and application.
Leads entrance calls, exit conferences, and technical calls with delegates.
Collaborates with cross-functional teams, including but not limited to Legal, Compliance, Quality Assurance to address compliance-related challenges and delegate’s performance deficiencies, and implement effective solutions.
Assists management to establish processes to track program effectiveness; monitor and analyze data to identify trends and areas for improvement.
Works closely with Delegation Oversight Audit management on and to co-lead projects.
Prepares and presents comprehensive reports and presentations to senior leadership, internal Committees, external entities, summarizing compliance activities, findings, and recommendations.
Reviews and provides feedback on work papers of other Auditors to ensure accurate testing, results, and reports, and to ensure adherence to departmental procedures and protocols.
Develops and delivers compliance training programs for internal staff members, such as Delegation Oversight Audit team, and other business units within L.A. Care.
Develops training programs for delegates as external entities ensuring awareness of compliance requirements and promoting a culture of compliance throughout the organization and with delegates.
Leads and manages compliance projects and initiatives, auditors’ trainings.
Develops training materials, updates audit tools, performs risk assessments, policy development, and process improvement efforts.
Perform other duties as assigned.