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Regulatory Compliance Auditor

2 months ago

New York, New York, United States Metropolitan Jewish Health System Full time

Overview: The ongoing challenges in providing affordable healthcare present unique opportunities for growth and improvement. Metropolitan Jewish Health System is committed to enhancing our services to meet the evolving needs of our patients and members. Our healthcare plans are crafted to empower individuals to maintain their independence and quality of life.

Position Summary: Reporting to the Compliance Officer and under the guidance of the Compliance Department leadership, the Compliance Auditor plays a critical role in executing assigned projects aimed at ensuring adherence to Medicare (Part C and D), New York State Medicaid, and Managed Long-Term Care (MLTC) regulations. This position involves initiating and conducting audits and monitoring activities across various health plan operations, including but not limited to appeals and grievances, claims processing, medical management, customer service, provider relations, contracting, sales, and enrollment.

Key Responsibilities:

  • Conduct thorough audits to ensure compliance with governmental regulations and organizational policies.
  • Develop and implement comprehensive audit plans, protocols, and corrective action strategies.
  • Perform root cause analyses and prepare impact reports to address compliance issues.
  • Engage effectively with all levels of management and collaborate with federal and state regulatory agencies.
  • Utilize advanced Excel skills for data analysis, charting, and dashboard creation.

Qualifications:

  • A Bachelor's Degree is required.
  • A minimum of three years of auditing experience is essential.
  • Experience in compliance within the healthcare sector, particularly with Medicare and Medicaid managed care, is advantageous.
  • Familiarity with facilitating regulatory audits, including those conducted by CMS, DOH, and DFS, is preferred.
  • Strong verbal and written communication skills are crucial for success in this role.