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Compliance Reviewer/ Examiner

5 months ago

Tampa, United States STRATEGYGEN CO Full time
Job DescriptionJob Description
Job Summary
We are seeking an experienced Compliance Reviewer/Examiner to join our team The Compliance Reviewer/Examiner is responsible for conducting onsite or desk audit compliance reviews under the Affordable Care Act regulation. They would also act as a Point of Contact and Owner of selected audit reviews based on rotations within the team. As a POC (PCO) they will be responsible for successful execution of the assigned compliance audit. The potential candidate should have good time management and prioritization skills in addition to a healthcare and audit background.

The ability to work under minimal supervision while delivering high-quality products on time is vital for this position. This position also requires the candidate to self- motivate and to conduct independent research for questions they may have. It is critical that they have an innate ability to learn new things and are open to constructive criticism.

The candidate will have good communication and personal skills, and the ability to work cohesively with the team and follow the lead of the Senior Examiners and Examiner-in-Charge. The candidate should have skills and expertise to assume ownership of the assigned review such as organizing work and assigning tasks within the team; ensuring that testing steps are completed on time and with the highest quality possible; providing regular updates; and escalating risks and issues to the Examiner-in-Charge and Program Director.

Responsibilities/Duties:


  • Develop and prioritize the review schedule and levels of effort to ensure timely completion of audits/reviews
  • Perform research and analysis of regulatory updates and guidance issued by CCIIO to Qualified Health Plan Issuers to ensure that testing is current and consistent with the NAIC Market Regulation Handbook and federal regulations
  • Perform research and analysis of data obtained for specific Qualified Health Plan Issuers
  • Document the research and analysis that has been completed and provide supporting documentation for Findings, specifically documenting how operational areas are not in compliance or where errors are identified
  • Use audit software (TeamMate) by completing all required sections and all work within the appropriate work areas
  • Prepare draft report and exhibits to summarize all Findings
  • Modify audit software to accurately reflect the report as issued after edits have been incorporated
  • Identify Findings requiring a Work Plan and monitor the completion of work plans by the Issuer
  • Modify report to accurately explain how the work plan was completed for final reports
  • Create and maintain project deliverables and reports to support contractual and regulatory compliance
  • Review and support the update of examination protocols when new regulations are released to ensure that they reflect the latest information

Education & Experience:


  • Bachelor's Degree plus 3 years of relevant experience or Masters Degree and 1 years of relevant experience
  • Market Conduct Management (MCM) insurance designation
  • Accredited Insurance Examiner (AIE) and Certified Insurance Examiner a plus
  • TeamMate software experience desired

Specific Knowledge & Skills:


  • An extensive knowledge of Local, State, and Federal laws and regulations pertaining to the Affordable Care Act (ACA), health insurance, and/or healthcare services
  • Knowledge of health care laws and regulations (HIPAA, ERISA) a plus
  • Significant experience in the health insurance sector, specifically related to health care compliance, health care regulations, health care auditing, or fraud investigation
  • Strong understanding and commitment to professional auditing standards
  • High-level attention to detail
  • Excellent communication and writing skills in proper language according to the general rule

This is a remote position.