Resp & Qualifications
This position will work in collaboration with the Manager of Regulatory Compliance in coordinating Consumer Direct SBU internal audits; conduct regular review and audit of internal controls within each functional area for strengths and weaknesses ensuring special focus allocation to the specific risk areas creating the highest exposure. Coordinate the follow-up process for audit findings; develop and implement a corrective action plan for any areas identified as risk exposure. Provide regular monitoring and control of the corrective action plan implementation. Communicate the risks associated with the control deficiencies identified along with regular investigative, analytic and audit reporting data to all stakeholders. This position has responsibility for the preparation and communication of the monthly status report for CD SBU State of Compliance. Integrate processes designed to support the implementation of all state and federal mandates to include work necessitated by future changes in the dynamic ACA environment. Incorporate complete transparency and accountability through the creation and maintenance of auditable supporting documentation such as Policies and Procedures, SOPs, workflows, and training materials.
PRINCIPAL ACCOUNTABILITIES: Under the direction of the Manager of SBU Regulatory Compliance, the principle duties and responsibilities include, but are not limited to, the following:
• Coordinate and conduct internal audits assigned by the Compliance Manager and the Director of Performance, Development, Compliance and Analysis.
• Continuously analyze and align all functional area Policies and Procedures, SOPs, workflows, and systems and ensure they are in compliance and alignment with regulations and remain updated and current
• Review complex business processes, systems, workflows, SOPs, Policies and Procedures and policies to identify, document, and elevate the presence of risks and trends within, that may be non-compliant with contracts and or statutory requirements especially in the claims processing, enrollment and service arenas – all jurisdictions, all products, all processing platforms to include our subsidiaries and vendors.
• Review internal controls, both manual and automated, and/or management controls in each functional area to remove any risk or exposure.
• Analyze controls for strengths and weaknesses ensuring special focus allocation to the specific risk areas creating the highest exposure to the Business Unit.
• Review audit findings with appropriate management staff to ensure accuracy. Perform follow-up activities related to audits/reviews and special projects and ensure corrective action and remediation occurs. Perform internal follow-up audits on each functional group to ensure that the department has implemented corrective actions. Prepare audit report on follow-up audit activities.
• Work with SBU management to establish and implement corrective action plan as an outcome of any audit findings.
• Assist SBU management in discharging their responsibilities by mitigating risks, safeguarding assets, identifying fraudulent activities, complying with laws and regulations directly tied to operational efficiency.
• Monitor, assess, and report significant matters to the Compliance Manager and the Director of Performance, Development, Compliance and Analysis.
• Remain abreast of emerging issues and developments that have direct impact on the Business Unit.
• Apply continuous Quality Improvement principles to system, processes, departmental data and other relevant problems affecting audit and reporting requirements using analytical and problem resolution skills.
• Determines most appropriate solution and provides recommendations for solutions and/or corrective action.
• Update and maintain departmental reports for internal use and for distribution to senior management.
Must have a Bachelor’s degree, Degree in Health Care Administration, Compliance, Health Policy, or Business Administration preferred, or demonstrated equivalent work experience. Must have excellent written and oral communications skills, analytical and computer capabilities. Must have a minimum of 2-3 years of experience in health care administration, compliance, claims, services, health policy or related field.
Travel is necessary to coordinate audit primarily in both the DC and MD offices and other sites as required.
Must have good interpersonal skills, ability to organize large projects and manage multiple priorities. Must have demonstrated innovation and creativity in problem solving. Must be flexible and self-motivated.
Must be able to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Preferred: Knowledge of health care with emphasis on managed care. Experience using inter-relational databases and project management software. Consumer Direct business and operational experience
Department: Large Group Regulatory Compliance
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.cascicareers.com
Please apply before: 04/05/2019
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The employee is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship