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Quality Assurance Auditor
2 months ago
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.
Position Summary: Reporting to the Compliance Officer and under the guidance of the Compliance Department leadership, the Compliance Auditor plays a crucial role in ensuring adherence to Medicare (Part C and D), New York State Medicaid, and Managed Long-Term Care (MLTC) regulations. This position involves independently managing assigned projects to uphold the health plan's compliance standards.
Key Responsibilities:
- Conduct 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.
- Ensure compliance with governmental regulations and internal health plan policies.
- Develop and implement comprehensive audit plans, protocols, corrective action plans, root cause analyses, and impact reports.
- Facilitate interactions with all levels of management and collaborate with federal and state regulatory agencies.
Qualifications:
- 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 preferred.
- Familiarity with regulatory audits, including those conducted by CMS, DOH, and DFS, is advantageous.
- Strong ability to independently conduct audits and develop actionable plans.
- Excellent verbal and written communication skills are critical.
- Proficiency in Excel and experience with data analysis, charting, and dashboard creation are necessary.
