This position requires the candidate to leverage prior experience to gain an understanding of the risks inherent in the operational processes that support the company and its related subsidiaries. This role requires a self-motivated individual that will lead projects and interact with all levels of management to identify opportunities and make recommendations to improve internal controls and operational effectiveness and efficiency. The ideal candidate will have an interest in gaining a high level understanding of the health insurance industry and related activities that support the organizations mission to help people and communities achieve better health.
- Execute ongoing monitoring and independent assessment activities that measure operational performance related to contract compliance (provider and vendor), policy compliance, internal/MAR/SSAE18 control effectiveness and related processes to prioritize and manage risk, identify gaps, drive process improvement, and remediate instances of non-compliance.
- Ability to perform analysis and document sound conclusions.
- Provide consultative services to assist management in evaluating existing and designing new processes that achieve completeness, accuracy, and timeliness of transactional processing, adherence to applicable regulatory requirements (e.g. CMS, NCQA), and contractual compliance.
- Assist in the facilitation of internal and external audits within the Service Organization. Serve as single point of contact related to SSAE18 audits to maintain/gather supporting documentation, respond to inquiries in support of the review on behalf of operational areas.
- Establish strong relationships and collaborate with Internal Audit, Legal Affairs, Risk Mitigation, Corporate Compliance and other applicable areas to facilitate and independently assess operational compliance with applicable regulations including OIR, FEP/OPM, NCQA, CMS and State of Florida for commercial and Medicare business.
- Assist in development of reporting mechanisms and metrics to measure operational performance and compliance.
Minimum Job Requirements
- Bachelor's degree or equivalent work experience
- 4+ years of internal or external audit experience, internal control design/testing, contract related experience
- Ability to draw sound conclusions from qualitative and quantitative data.
- Ability to maintain confidentiality regarding sensitive information.
- Strong interpersonal skills and the ability to influence and accomplish results through others, including persons not in the "chain of command"
- Strong written and oral communication skills
- Organization, facilitation, communication and presentation skills
- Experience working with Federal, State and industry regulations/guidance
- Knowledge of federal, state, and industry compliance processes, regulatory oversight procedures, and related policy development
- Some travel required
- Experience conducting on-site assessments of vendor/delegated entity processes and/or emulating an external audit for the purpose of assessing risk and compliance.
- Licensed CPA, CIA or CISA
- Knowledge of healthcare industry, including healthcare risk management
- Project management experience
- Proficiency in Microsoft Office (Word, Power Point, Outlook and Visio)
- Strong Excel skills including Pivot Tables and V-Look Ups.
- Knowledge of documenting walkthroughs, narratives, and flows for control identification and testing