Logo of Huzzle

Appeals & Grievances Regulatory Audit Readiness Specialist II

  • Job
    Full-time
    Senior Level
  • Customer Relations
    Healthcare
  • Los Angeles

AI generated summary

  • You need a Bachelor’s degree (or equivalent experience), 5 years in regulatory auditing in healthcare, Medi-Cal and Medicare knowledge, strong skills in Tableau, Word, Excel, and Access.
  • You will ensure audit readiness, evaluate regulatory compliance, collaborate on process improvements, analyze QA scorecards, and communicate findings through reports and presentations.

Requirements

  • Bachelor's Degree
  • In lieu of degree, equivalent education and/or experience may be considered.
  • A minimum of 5 years of experience in regulatory auditing (Appeals & Grievances, Call Center, Enrollment) in a healthcare environment required.
  • Previous experience with Medi-Cal and Medicare in a managed care environment.
  • Tableau experience.
  • Advanced computer proficiency, Word, Excel; and Access is required.
  • Strong analytical and team building skills.
  • Ability to work effectively with diverse team members.
  • Ability to formulate recommendations to improve quality and service delivery, and develop effective system and process improvements.
  • Ability to multi-task and streamline day-to-day operations.
  • Ability to track and trend and create regulatory reporting.
  • Strong interpersonal and organization skills and is expected to work independently within the department's established guidelines, policies and procedures.
  • Licenses/Certifications Required
  • Licenses/Certifications Preferred
  • Required Training
  • Light

Responsibilities

  • 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 and procedures. Conducts interviews, reviews documents, develops and administers surveys, composes summary memos and prepares working papers. Identifies, develops, and documents audit issues and recommendations using independent judgement concerning areas being reviewed. Communicates or assists in communicating the results of audit and consulting projects via written reports and oral presentations to Customer Solution Center management. Collaborates with business units in audit universe preparation and validation. Assists in document preparation for regulatory and internal audits.
  • Regulatory compliance: Works closely with Customer Solution Center Management to determine and handle effectiveness/accuracy of operational processes. Collaborates with internal Subject Matter Experts (SMEs) to understand Customer Solution Center regulatory processes and assists with getting to the root cause of identified deficiencies. Evaluates policies and procedures with applicable regulations/guidelines and provides recommendations to management for continuous process improvements.
  • Collaborates with Customer Solution Center Business Analyst to track, trend, and analyze results of Quality Assurance (QA) scorecards for training and quality improvement.
  • Perform other duties as assigned.

FAQs

What is the job title for this position?

The job title is Appeals & Grievances Regulatory Audit Readiness Specialist II.

What is the location of the job?

The job is located in Los Angeles, CA.

What is the salary range for this position?

The salary range is $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.).

What is the required education for this position?

A Bachelor's Degree is required, although equivalent education and/or experience may be considered in lieu of a degree.

How many years of experience are required for this role?

A minimum of 5 years of experience in regulatory auditing in a healthcare environment is required.

What specific experience is preferred for this position?

Previous experience with Medi-Cal and Medicare in a managed care environment is preferred.

What technical skills are required for this job?

Advanced computer proficiency in Word, Excel, and Access is required.

Will this position require after-hours work?

Yes, this position may require work after hours, on weekends, holidays, and has flexibility in hours/shift in critical situations.

What does the job involve regarding audit readiness?

The job involves performing audit procedures, identifying and defining issues, reviewing and analyzing evidence, and documenting processes and procedures for audit readiness.

Are there benefits associated with this position?

Yes, L.A. Care offers a wide range of benefits including Paid Time Off (PTO), Tuition Reimbursement, Retirement Plans, Medical, Dental, Vision, a Wellness Program, and Volunteer Time Off (VTO).

https://www.linkedin.com/company/lacarehealth/about/#:~:text=Care%20Health%20Plan-,Elevating%20health%20care%20for%20all

Science & Healthcare
Industry
1001-5000
Employees
1997
Founded Year

Mission & Purpose

L.A. Care’s mission is to provide access to quality health care for L.A. County’s low-income communities, and to support the safety net required to achieve that purpose. As a publicly operated health plan, L.A. Care Health Plan serves more than 2.9 million members in Los Angeles County, making it the largest publicly operated health plan in the country. L.A. Care offers four health coverage plans including Medi-Cal, L.A. Care Covered™, L.A. Care Medicare Plus and the PASC-SEIU Homecare Workers Health Care Plan, all dedicated to being accountable and responsive to members. L.A. Care prioritizes quality, access and inclusion, elevating health care for all of L.A. County