Compliance Auditor

Position Summary:

CQM auditor performs Quality Monitoring to assure the regulatory compliance and quality of process in daily Utilization Management (UM) activities with minimal to moderate supervision. The auditor will work closely with the business units, Data Analysts and UM compliance to promote high quality, efficient and effective prior authorization process. The auditor will be able to drive and present UM case files and complete interview with manger in any health plan or regulatory audit as well as work with business units for cap responses and remediation. This position requires knowledge of comprehensive regulation, UM policies & procedures, UM audit and quality improvement.

Essential Duties and Responsibilities include the following:

• UM auditor must be familiar with UM regulations, UM process and UM system.
• The role is assigned specific projects to monitor and audit the daily UM activities through reports and case files review for any cases not requiring clinical decisions.
• The role will cooperate with nurse auditors to complete auditing case files that require clinical personnel for decisions.
• The role will be able to monitor any changes to a case file after the decision was made, and request appropriate remediation.
• The role will be able to drive and present case files for any questions not related to clinical decisions.
• The role will be able to monitor and request remediation when applicable to UM system control including receive dates changes.
• Summarize the quality monitoring findings, analyze root causes and propose of quality improvement plans.
• Prepares and conducts focus monitoring to the areas needs to be improved based on daily monitoring findings, health plan audit results, and executive management requirements.
• Work with decision support to create and improve the UM monitoring reports.
• Ensure all assigned projects being completed within required timeframe and report to CQM audit Supervisor.
• Collaborate with UM team to ensure any focus audited area being monitored, and the quality of process being tracked.
• Work with operational teams to monitor the effectiveness and efficiency of the process change made for quality improvement.
• Ensure new process procedure being implemented accurately through reports and case files review.
• Report issues found to prior authorization compliance director based on findings.
• Maintain and track daily reports received from decision support team.
• Attend department meetings, in-house service, trainings and complete acknowledgement within required timeframe.
• Other duties as assigned.

The pay range for this position at commencement of employment is expected to be between $30 and $32 hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Education and/or Experience:

• High School or above graduated.
• Minimum 2 years of UM or Prior authorization work experience.
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and Power Point).
• Typing 60 words per minutes with accuracy.
• Ability to deal with responsibility with confidential matters.
• Must have strong analytical, creative problem solving, and organizational skills.
• Ability to work in a multi-task, high stress environment.
• Ability to strategize effectively, execute within timelines, and deliver quality results
• Ability to thrive in a fast-paced environment where flexibility and being proactive are essential
• Must be able to handle multiple projects at one time, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.
• Must be self-motivated, pleasantly aggressive and realistically ambitious and have high personal ethics.
• Must have the ability to work with all levels of management and have the ability to develop positive working relationships with different divisions in the company.