Summary: The Compliance Auditor helps to ensure that the organization is in compliance with all Local, State, and Federal laws, rules, and regulations by conducting compliance audits and assisting with internal monitoring activities pursuant to the corporate Compliance Program. The Auditor executes audits as directed, evaluates and tracks corrective actions, and provides compliance audit and monitoring support to various functional units of the organization.
Bachelor's degree (B. A. / B. S.) from four-year college or university or 2 additional years of experience; Minimum 3 years experience in a managed care, health care, insurance, or other federally regulated environment, in a role that required interpreting, understanding, and implementing government regulations.
Certificates and Licenses:
Certified in healthcare compliance
Duties and Responsibilities include the following. Other duties may be assigned.
Execute internal compliance audits as assigned to systematically review specific functional areas of the organization for compliance with applicable laws, regulations, policies, procedures, and the Company’s Compliance Program requirements, specifically in the areas of Medicare Advantage (Part C) and Prescription Drug (Part D) regulations.
Conduct internal audit interviews with Department Heads when necessary for completing assigned audit work.
Prepare audit work papers and reports to effectively conduct, document, and communicate all compliance audit activities. Compose audit reports which accurately outline any findings as a result of the audit work.
Meet with Compliance Officer to review audit reports, discuss findings, and corrective action plans.
Review proposed corrective action plans in response to audit findings; collaborate with Compliance Officer on any necessary changes.
Track corrective actions and follow-up with responsible parties to ascertain completion status. Report deficiencies or roadblocks to supervisor and collaborate on actions needed for the responsible parties to successfully complete requirements to achieve compliance.
Review corrective action plan evidence to assess whether all corrective actions were taken appropriately and that the evidence demonstrates compliance with all applicable regulations.
Compile data to report on audits performed, findings, level of risk, corrective action plans, and outcomes. Assist in evaluating the effectiveness of the audit program.
Participate in risk assessment activities relative to Medicare Advantage Parts C and D; assist with the development of an annual audit plan that identifies and prioritizes areas of significant compliance risk.
Assist supervisor with internal monitoring initiatives.
Assist supervisor in preparing for and coordinating regulatory audits.
Maintain education, awareness, and knowledge of current regulations and best practices in the health care industry and in the audit and monitoring function. Bring regulatory changes and matters of significance or urgency to the supervisor’s attention.
Communicate the status of operational projects to supervisor, internal individuals and/or teams, and external clients, in a timely manner.
Continuously communicate the message of compliance in all interactions with others. Assist in compliance awareness, training, and education initiatives by contributing to internal newsletters, participating in educational activities and events, and other activities as requested or developed.
Other related duties as assigned to meet departmental and Company objectives.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are a representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to write speeches and articles for publication that conform to prescribed style and format. Ability to effectively present information to top management, public groups, and/or boards of directors.
Ability to comprehend and apply principles of advanced calculus, modern algebra, and advanced statistical theory. Ability to work with concepts such as limits, rings, quadratic and differential equations, and proofs of theorems.
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
To perform this job successfully, an individual should have Proficiency using Microsoft Office software applications, including Word, Excel, and Power Point; adept at learning and utilizing database and document repository applications; proficient in report development.
Knowledge, Skills and Other Abilities:
- Working knowledge of compliance audit and monitoring techniques and standards, including use of web-based audit and monitoring applications or the ability to quickly learn such applications.
- Understanding of the risks and controls associated with healthcare regulatory compliance processes and the ability to identify those risks and controls.
- Knowledge of Medicare Advantage and Part D regulatory requirements. Ability to research, read, analyze, and interpret State and Federal laws, regulations, and standards.
- Excellent written and verbal communication and presentation skills, with ability to effectively and professionally communicate with individuals at all levels of the organization, as well as external parties.
- Excellent problem-solving skills.
- Analytical skills, including research skills, with ability to interpret data, analyze and disseminate information in a readily understandable manner.
- Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions.
- Ability to plan proactively and interpret complex processes and programs. Excellent follow-up skills to keep projects and tasks on track.
- Energetic and forward thinking with high ethical standards and a professional image.
- Collaborative and team-oriented.
- Ability to meet stringent deadlines, multi-task, perform a high volume of activities, prioritize work, and respond to changing demands.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to walk; sit and use hands. The employee is occasionally required to stand.