Compliance Audit Services Specialist, Senior
Company: Blue Shield of California
Location: Monterey Park
Posted on: March 21, 2020
At Blue Shield of California we are parents, leader, students,
visionaries, heroes, and providers. Everyday we come together
striving to fulfill our mission, to ensure all Californians have
access to high-quality health care at a sustainably affordable
price. For more than 80 years, Blue Shield of California has been
dedicated to transforming health care by making it more accessible,
cost-effective, and customer-centric. We are a not-for-profit,
independent member of the Blue Cross Blue Shield Association with
6,800 employees, more than $20 billion in annual revenue and 4.3
million members. The company has contributed more than $500 million
to Blue Shield of California Foundation since 2002 to have a
positive impact on California communities. Blue Shield of
California is headquartered in Oakland, California with 18
additional locations including Sacramento, Los Angeles, and San
Diego. We're excited to share Blue Shield of California has
received awards and recognition for - LGBT diversity, quality
improvement, most influential women in corporate America, Bay
Area's top companies in volunteering & giving, and one of the
world's most ethical companies. Here at Blue Shield of California,
we're striving to make a positive change across our industry and
the communities we live in - Join us!
Compliance Audit Services, Specialist, Senior
Responsible for performing regulatory/contractual delegation
oversight control audits to ensure compliance with Federal and
State regulatory agencies. Assures compliance to external
specifications and standards. Conducts comprehensive regulatory
reviews using a standard audit model.
Includes monitoring and review of self-reported compliance,
developing an audit plan, executing the audit, identifying
corrective action opportunities, creating a final report, and
following up on outstanding issues.
Responsible for monitoring and reporting operational timeliness of
delegated providers and other delegated entities to assure
compliance to federal and state regulatory requirements and
standards including but not limited to Blue Shield Promise
contractual specifications and standards.
Responsible for instituting corrective action for non-compliance.
Negotiates corrective action plans.
Participates in the development of training. Develops
correspondence to external entities.
Coordinates auditing process with external providers and internal
Manages internal & external data reporting on compliance,
interdepartmental performance reviews, and monthly claims
delegation compliance reviews.
Responsible for revision of policies and procedures to comply with
regulatory changes and for training internal staff or delegated
Participates in projects and taskforces as assigned.
Responsible for making moderate to significant improvements of
processes, systems or products to enhance performance of job
Other duties as assigned.
INNOVATION & COMPLEXITY:
Issues faced are numerous and undefined, and require detailed
information gathering, analysis and investigation to understand the
problem. Problems are difficult and moderately complex, typically
impact multiple departments or specialties, and are usually solved
through drawing from prior experience and analysis of issues.
Develops new perspectives and innovative approaches on existing
COMMUNICATION & INFLUENCE:
Communicates with parties within and outside of own job
Has responsibility for communicating with parties' external to the
organization (e.g., customers, vendors, etc.).
Works to influence parties within and outside of the job function
at an operational level regarding policies, procedures and
LEADERSHIP & TALENT MANAGEMENT:
Generally, responsible for providing guidance, coaching and
training to other employees within job area.
Generally, responsible for managing major/complex projects
involving delegation of work and review of work products.
Requires a college degree or equivalent in managed Health Care
experience with a minimum of 5 years
5 years' experience in claims, health care auditing and operational
Extensive knowledge of DMHC, DHCS and CMS regulatory requirements
and guidelines, Viewed as a subject matter expert within claims and
Excellent analytical and problem-solving skills.
Keywords: Blue Shield of California, Monterey Park , Compliance Audit Services Specialist, Senior, Accounting, Auditing , Monterey Park, California
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