Health Plan Compliance Auditor

Banner Health•Phoenix, AZ

9d•Hybrid

About The Position

In this role you will support compliance oversight regarding Banner Health Plans and Networks. Key responsibilities include investigating issues, performing risk-based regulatory compliance audits, preparing audit reports, and evaluating documentation supporting remediation of compliance action plans. This position is hybrid for candidates residing in Arizona. The shift is Monday-Friday, 8:00am-5:00pm. Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care. POSITION SUMMARY This position ensures compliance through auditing and monitoring of operational areas (policy and procedures) or providers and regulatory requirements of the health plan. This position works both independently and collaboratively with all health plan functional areas to develop, implement, maintain and evaluate contractually compliant operational practices. Report findings to Operations Management to utilize for process improvement. Develop training programs for managed care staff based on audit findings and regulatory guidance.

Requirements

Two to four years of auditing/training experience in an insurance and/or healthcare environment and four to six years managed care or health care experience required.
In-depth knowledge and experience with AHCCCS and Medicare.
Applicable experience in various functional areas of health plan/health care operations.
Must have an exemplary background in maintaining confidentiality and handling sensitive information.
Ability to interpret complex regulatory requirements and proven ability to build relationships and interface with people in a positive manner.
Strong working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint) and strong organizational/analytical, written and verbal communication skills.
Excellent customer service skills, both internal and external and the ability to work independently.
Depending upon assigned area of responsibility, position may require applicable certifications and/or licensures, including but not limited to: Certified Coding Specialist (CCS) or Certified Professional Coder (CPC)

Nice To Haves

College coursework, degree or related work experience is preferred.
Additional related education and/or experience preferred.

Responsibilities

Maintains working knowledge of AHCCCS and Medicare rules and regulations (may also include knowledge of CPT, ICD-9 coding, HCPCS and DRGs). Researches regulatory requirements and develop/update audit tools to evaluate health plan compliance against regulatory requirements. Utilizes resources such as payment guidelines, AHCCCS AMPM and other resources as they impact departments.
Develops, conducts and documents specialized audits as needed and as requested. Audits specified operational areas as identified and documented in the Audit Plan within the health plan (such as claims, system analysts and referral coordinators) or provider audits. Prepares audit summary documents and report and benchmark results of audits to the Compliance Department management team. Validates implemented Corrective Action Plans (CAPs) to ensure assigned functional areas are performing in a compliant manner.
Meets with assigned functional area management team to communicate audit activities and outcomes of assigned audits. Effectively articulate government requirements to all levels of staff. Assists managerial staff in developing and maintaining specific work procedures, policies and procedures and process improvement projects.
Conducts varied assignments and investigations, performs and analyzes systems, and assists the Compliance management team to update the annual Audit Work Plan. Develops individual and group training programs and materials based on need indicated from audit and updated policies and procedures.
Under general direction, assists in the analysis of the company's regulatory compliance posture and the development of control recommendations. Consults with product management, claims and sales management to keep abreast of functional area changes. Reviews recent proposed activities by regulatory agencies to determine potential impact on company operations. Perform in-depth analysis of regulatory changes and ensure assigned functional areas are implementing/revising processes to be in compliance with program requirements. Participate in functional area work groups to implement compliant processes. Develop desktops to support day-to-day activities.
Assists with the analysis and interpretation of regulatory compliance requirements especially as they relate to the Health Plans and assigned functional areas or providers. Understands and monitors assigned functional areas compliance metrics (e.g., dashboards) to determine whether assigned functional areas may be at risk for non-compliance with government requirements. Conducts detailed analyses of assigned functional areas to ensure in-depth understanding of all functional area requirements.
Assists Compliance Management in monitoring and reviewing regulatory and legislative changes, preparing company’s response to regulatory changes and following up with appropriate areas to ensure required changes are implemented.
The scope of this position is broad both in clientele (entire health plan work force or providers) and in topical areas that need to be addressed (laws and regulations that are within the scope of health plan compliance). Represents compliance when participating on committees and in work groups. The position must engage in conducting highly confidential work and ensuring compliance with managed care regulations. The position will be required to work cooperatively with a variety of departments or providers.

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