Compliance Specialist and Auditor

Network Health s success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Compliance Specialist and Auditor.The Compliance Specialist and Auditor will assist the Compliance department with updating, enhancing and administering all aspects of the Compliance and Integrity Program. The incumbent will provide auditing and review assistance for all aspects of operations and compliance initiatives, and will assist in improving the internal control environment at Network Health. The Compliance Specialist and Auditor will further be responsible for the identification of risk areas and the interpretation and implementation of contract requirements to ensure compliance with applicable laws and regulations. This individual will report findings, recommend improvements and corrective actions.

Essential Job Duties:

  • Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health

  • Demonstrate understanding of State and Federal guidelines and requirements related to insurance operations and compliance, as well as assist with the interpretation, distribution, and implementation of new and/or updated regulations or guidance

  • Assist the Compliance Officer in developing compliance audit instruments and protocols; revise policies and procedures; design, implement and conduct adequate training under the direction of the compliance director to comply with regulatory changes

  • Responsible for the management and retention of key business documents in accordance with document retention guidelines as well as Network Health s record retention policy

  • Assist the Compliance Officer with implementation of the monitoring and auditing plan for all operational areas; serve as an additional on-site compliance resource for Network Health, consulting with the Compliance Officer where appropriate

  • Maintain Compliance intake forms, respond appropriately to issues raised, and track any corrective actions necessary

  • Assist the Compliance Officer in evaluating the adequacy and effectiveness of internal controls for compliance with regulatory requirements

  • Assist the Compliance Officer with granting access to computer systems maintained by the State and Federal governments

  • Assist the Compliance officer with developing and implementing tools and procedures for assessing the risk of operations and applicable vendors that perform administrative functions on behalf of Network Health.

  • Review vendor contracts and track the designation of First Tier, Downstream or Related Entity or Offshore Subcontractor status, and report such statuses to the Centers for Medicare and Medicaid Services, as necessary.

  • Responsible for reviewing materials intended for members, agents and/or providers to ensure materials meet all requirements outlined by the State and Federal regulations

  • Responsible for facilitating, gathering and submitting data and other documentation from operational areas for external audit and data validation requests.

  • Conduct audits of all departments involved in the delivery or administration of Network Health s insurance plans for compliance with State, Federal and Network Health standards

  • Perform internal compliance investigations and assess operational risk

  • Provides one-on-one or small group training sessions with individuals, departments, coders and other staff based upon the results of audits performed.

  • Performs other duties and responsibilities as assigned.

Skills Required:

  • Strong verbal, written, research and analytical skills

  • Exceptional project management and interpersonal skills

  • Strong attention to detail

  • Must be self-motivated, able to work independently.

  • Must be able to work effectively with highly interdisciplinary teams

  • Excellent communication, critical thinking and decision making skills

  • Excellent time management skills with ability to prioritize and manage multiple, projects and demands

Minimum Education Required:

  • Associate Degree or four years of related experience required

  • Bachelor s Degree preferred

Minimum Related Years of Experience (per minimum education) Required:

  • Minimum three (3) years of insurance or health care compliance required

  • Clinical or billing/coding experience is strongly preferred

  • Experience with CMS requirement related to MAPD and PDP operations preferred

  • Experience with CMS, state and federal regulations and laws impacting Medicare Managed Care and Medicare Part D preferred

  • Experience with process improvement/maximum operational efficiency preferred

Network Health is an affirmative action and equal opportunity employer.

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