PRINCIPAL RESPONSIBILITIES:
Under the general direction of the Supervisor, Health Plan Audits,this position is responsible for supporting the Alameda Alliance for Health's (AAH) Compliance Program, with an emphasis on external/delegate auditing activities.
Principal responsibilities include:

Lead and/or coordinate external audits of AAH delegated entities to ensure compliance with regulatory and contractual requirements and controls.Recommend opportunities to strengthen the external audit control structure.

Coordinate the scheduling of delegated audits.
Conduct regularly scheduled and ad-hoc audits of delegated entities to ensure compliance with regulations and controls by examining and analyzing records, reports, operating practices and documentation.
Develop and update audit tools to account for all current regulatory requirements.
Create and Implement the development of and the monitoring of corrective action plans resulting from delegated audits to mitigate risks.
Recommend opportunities to strengthen controls.
Develop, plan and coordinate preparatory "mock" audits, including reviews of policies & procedures, DMHC & DHCS technical assistance guides (TAGs), conduct question and answer sessions, and lead departments through audit prepatory measures as needed.
Assist in management of the AAH audit calendar.
Present audit findings to the Alliance Compliance Committee for review, discussion, and approval at least quarterly, or sooner if necessary.

Examine and analyze records, reports, operating practices and documentation.
Coordinate with external regulatory agencies and Alliance's internal departments on documentation requests and submissions, preparing for audit onsite visits, and corrective action plan responses.
Assist in the development of Alliance's policies and procedures and monitoring of the annual policy review process.

Train and assist various delegated entities in developing best practices in their operations in accordance with established policies and procedures.
Assist in reviewing policies for updating to include regulatory standards.

Maintain a strong working knowledge of state and federal legislation, statutes and regulations, and local, state, and national health issues affecting publicly-funded managed care organizations and the Alliance.

Maintain knowledge of business products and related Alliance policies and procedures.
Research and interpret Knox-Keene Act, Title 22 and Department of Health Care Services (DHCS) regulations.
Monitor regulatory/compliance climate and escalate issues when necessary.

Complete other special projects and duties as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

Audit delegated entity, external and internal processes as needed.
Develop and update audit tools, reports, and criteria metrics as needed.
Research, interpret, and provide analysis of state and federal legislation, statutes and regulations as applicable to company policies and procedures.
Communicate effectively and efficiently internally and externally.
Comply with, and support the organization's compliance with, the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

Constant and close visual work at desk or computer.
Constant sitting and working at desk.
Constant data entry using keyboard and/or mouse.
Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
Frequent walking and standing.
Occasional driving of automobiles.

Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:

Bachelors of Arts or Bachelors of Science degree required.
Familiarity with Medicaid (Medi-Cal), Knox-Keene Act, and other publicly funded programs preferred.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

Two years of experience in health care, auditing, compliance, regulatory, investigation, and/or insurance/managed care experience required.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

Exemplary interpersonal skills, including ability to work effectively as part of a team across organizational structure.
Ability to analyze and interpret legislative, statutory, regulatory, and legal language.
Strong analytical problem-solving skills with initiative.
Ability to work independently is critical.
Strong organizational/documentation skills.
Strong project management experience preferred.
Ability to meet deadlines and adjust to changes in policies, procedures, and priorities.
Effective verbal and written communications skills.
Ability and willingness to take initiative to address problems and make continuous process improvements.
Ability to enforce and educate staff in Compliance areas, including established ethics and codes of conduct.
Ability to interface with senior management and translate complex issues into project plans with deliverables and measurable outcomes.
Proficient experience/comfort in use of computer software. Microsoft Word, Excel, Outlook, and PowerPoint as well as internet search skills mandatory.

SALARY RANGE $80,040.08-$120,0606.11 Annually
The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.