Overview
Appeals & Grievances Regulatory Audit Readiness Specialist II Jobs in Los Angeles, California, USA at L.A. Care Health Plan
Appeals & Grievances Regulatory Audit Readiness Specialist II
Job Category: Customer Service
Location: Los Angeles, CA, US, 90017
Position Type: Full Time
Requisition : 11884
Salary Range: $88,854.00 (Min.) – $ (Mid.) – $ (Max.)
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan, serving more than 2 million members.
Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County’s vulnerable and low-income communities and residents.
The Customer Solution Center (CSC) Audit Readiness Specialist II is responsible for the execution, oversight, and monitoring of the guidelines and protocols to ensure readiness for all regulatory audits. This position will develop, with the assistance of CSC management, a successful auditing strategy for the end-to-end processes within CSC. Responsibilities include maintaining CSC’s compliance program efforts, including policy and procedure development, training, and compliance enhancements.
This position will complete targeted, focused, and random audits related to member interactions and outcomes to ensure compliance. Results will be provided to management with recommendations for corrective actions. This position will be responsible for the regulatory obligations for each line of business.
Duties
Audit readiness: Performs audit procedures for Customer Solution Center departments to ensure readiness; including identifying and defining issues, developing criteria, reviewing and analyzing evidence, and documenting business unit processes. Conducts interviews, reviews documents, and prepares working papers. Communicates the results of audit and consulting projects via written reports and oral presentations.
Regulatory compliance: Works closely with management to determine and handle operational processes. Collaborates with internal Subject Matter Experts (SMEs) to understand regulatory processes and assists in identifying deficiencies. Evaluates policies and procedures and provides recommendations for continuous process improvements.
Collaborates with Business Analyst to track and analyze results of Quality Assurance (QA) scorecards for training and quality improvement.
Perform other duties as assigned.
Education
Required
Bachelor’s Degree or equivalent education and/or experience.
Experience
Required: A minimum of 5 years of experience in regulatory auditing in a healthcare environment. Previous experience with Medi-Cal and Medicare in a managed care environment.
Skills
Required:
Advanced proficiency in Word, Excel, and Access.
Strong analytical and team-building skills.
Ability to work effectively with diverse team members.
Ability to formulate recommendations for quality and service delivery improvements.
Ability to multi-task and streamline operations.
Strong interpersonal and organizational skills.
Physical Requirements
Light
Additional Information
This position requires work after hours, on weekends, and holidays, with a hybrid remote schedule and occasional flexibility in hours/shift in critical situations.
Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including:
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental, and Vision
Wellness Program
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Title: Appeals & Grievances Regulatory Audit Readiness Specialist II
Company: L.A. Care Health Plan
Location: Los Angeles, California, USA
Category: Healthcare, Quality Assurance – QA/QC
