Senior Compliance Examiner/Auditor – MLR exams

Examination Resources, LLC

94d • $95,000 - $120,000

About The Position

This role involves performing analytical reviews of documentation provided by companies to ensure compliance with state and/or federal legislation regarding MLR calculations and the distribution of rebates to enrollees. The position requires testing the accuracy and completeness of premium and claims transactions, reviewing Quality Improvement Activity (QIA) expenses, and examining Pharmacy Benefit Manager contracts and prescription drug claims data. The Senior Compliance Examiner/Auditor will interpret MLR regulations and technical guidance, and will be responsible for documenting examination conclusions and assisting in the creation of internal trainings and audit procedures.

Requirements

• Experience with MLR or healthcare insurance auditing or accounting required.
• Minimum 2+ years’ experience as an accountant, auditor, examiner or analyst with a state insurance department, public accounting firm, insurance company, or other entity involved in conducted MLR related audits.
• PC skills, including experience in using software for producing presentations, spreadsheets, and project planning (skilled in TeamMate, ACL/Access/Tableau, and MS Excel, Word and PowerPoint).
• Strong interpersonal, presentation, analytical and examination/audit skills.
• Excellent organizational skills and the ability to prioritize multiple tasks, projects and assignments using effective time management skills.
• Strong written and verbal communication skills.
• Dynamic/flexible demeanor with exceptional customer service skills.
• Must be self-motivated, work well independently and possess a sense of urgency.
• Ability to demonstrate ethical and professional standards as outlined by the Firm.

Nice To Haves

• Bachelor's Degree in Accounting or Finance is preferred, but not required.
• CPA, Certified Internal Auditor (CIA), Certified Financial Examiner (CFE), and/or Accredited Financial Examiner (AFE) preferred, but not required.

Responsibilities

• Perform analytical reviews of documentation provided by companies supporting MLR calculations and distribution of rebates to enrollees for compliance with state and/or federal legislation.
• Perform attribute and accuracy testing of premium and claims transactions, and other major components of the MLR calculation to determine completeness and accuracy.
• Review Quality Improvement Activity (QIA) expenses, which are costs for activities that improve the quality of care provided to members, ensuring reported costs meet the definition of QIA and that intercompany allocations are fair and reasonable.
• Review Pharmacy Benefit Manager contracts and detailed prescription drug claims data for compliance with applicable state laws and regulations.
• Interpret MLR regulations, filing instructions and technical guidance in comparison to documentation provided by companies.
• Write and/or supervise others in the written documentation of clear, concise, and informative conclusions on required MLR examination procedures.
• Assist and lead in the creation of internal MLR trainings and audit procedure creation.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior