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Banner Health · 9 hours ago

Health Plan Compliance Auditor

Phoenix, AZ

Full-time

Hybrid

Mid, Senior Level

6+ years exp

Banner Health is a nationally-recognized healthcare leader committed to fostering a strong, inclusive culture. In this role, you will support compliance oversight regarding health plans and networks, performing audits and preparing reports to ensure regulatory compliance.

Health CareInsuranceNon Profit

Responsibilities

Support compliance oversight regarding Banner Health Plans and Networks

Investigate issues, perform risk-based regulatory compliance audits, prepare audit reports, and evaluate documentation supporting remediation of compliance action plans

Maintain working knowledge of AHCCCS and Medicare rules and regulations

Research regulatory requirements and develop/update audit tools to evaluate health plan compliance against regulatory requirements

Develop, conduct and document specialized audits as needed and as requested

Prepare audit summary documents and report and benchmark results of audits to the Compliance Department management team

Validate implemented Corrective Action Plans (CAPs) to ensure assigned functional areas are performing in a compliant manner

Meet with assigned functional area management team to communicate audit activities and outcomes of assigned audits

Assist managerial staff in developing and maintaining specific work procedures, policies and procedures and process improvement projects

Conduct varied assignments and investigations, perform and analyze systems, and assist the Compliance management team to update the annual Audit Work Plan

Develop individual and group training programs and materials based on need indicated from audit and updated policies and procedures

Assist in the analysis of the company's regulatory compliance posture and the development of control recommendations

Consult with product management, claims and sales management to keep abreast of functional area changes

Review recent proposed activities by regulatory agencies to determine potential impact on company operations

Perform in-depth analysis of regulatory changes and ensure assigned functional areas are implementing/revising processes to be in compliance with program requirements

Participate in functional area work groups to implement compliant processes

Develop desktops to support day-to-day activities

Assist with the analysis and interpretation of regulatory compliance requirements especially as they relate to the Health Plans and assigned functional areas or providers

Understand and monitor assigned functional areas compliance metrics to determine whether assigned functional areas may be at risk for non-compliance with government requirements

Conduct detailed analyses of assigned functional areas to ensure in-depth understanding of all functional area requirements

Assist Compliance Management in monitoring and reviewing regulatory and legislative changes, preparing company’s response to regulatory changes and following up with appropriate areas to ensure required changes are implemented

Represent compliance when participating on committees and in work groups

Qualification

AHCCCS knowledgeMedicare knowledgeAuditing experienceMicrosoft OfficeRegulatory complianceCustomer service skillsAnalytical skillsTraining developmentProcess improvementCommunication skillsConfidentialityRelationship building

Required

Two to four years of auditing/training experience in an insurance and/or healthcare environment and four to six years managed care or health care experience required

In-depth knowledge and experience with AHCCCS and Medicare

Applicable experience in various functional areas of health plan/health care operations

Must have an exemplary background in maintaining confidentiality and handling sensitive information

Ability to interpret complex regulatory requirements and proven ability to build relationships and interface with people in a positive manner

Strong working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint) and strong organizational/analytical, written and verbal communication skills

Excellent customer service skills, both internal and external and the ability to work independently

Depending upon assigned area of responsibility, position may require applicable certifications and/or licensures, including but not limited to: Certified Coding Specialist (CCS) or Certified Professional Coder (CPC)