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Managed Care Compliance Specialist - Managed Care
Job Description
The Managed Care Compliance Specialist is responsible for assisting with the implementation of the internal auditing and monitoring program within the Managed Care department by ensuring compliance with applicable rules and regulations including but not limited to AB1455 and Medicare Claims Processing Guidelines. This position is responsible for maintaining routine auditing functions and providing feedback on departmental activities, to assure compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHCS.
Duties and Responsibilities:- Ensures all services provided to Commercial, Medicare and Medi-cal managed care members are in compliance with program regulations, insurance regulations, and regulatory requirements.
- Maintains and tracks laws and regulations, contract documentations, amendments, and various compliance measures pertaining to Commercial, Medicare and Medi-cal managed care.
- Develops policies, procedures, and processes to align with federal program regulations and any applicable state regulations pertaining to Commercial, Medicare and Medi-Cal managed care.
- Provides mentorship to various departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contract language for Commercial, Medicare and Medi-Cal managed care.
- Acts as a liaison with health plans and current CSHS departments to ensure both health plan regulations and CSHS policies are met.
- Coordinates and act as primary contact for all health plans audits, including leading all aspects of the review for performance management and accurate coding.
- Develops and supervise compliance with corrective action plans as a result of post-health plan audits and regulatory audits.
- Provides required Compliance and FWA trainings for existing, new employees and non-employees, as the need arises.
- Educates CSHS employees on company policies and procedures regarding access to care, the grievance and appeals process, the eligibility process, etc.
- Remains updated on all member and provider policy changes made by the health plan and/or the State.
- Acts as subject matter expert on health care laws/regulations as a compliance resource to CSHS and affiliates, including contracted and employed physician practices.
- Aggregates, analyze, and report audit results, identify error trends and root causes, and make recommendations for performance improvements.
Qualifications
Education:
High school diploma/GED required. Bachelor's degree in Healthcare or related field preferred.
Experience:
Five (5) years of compliance experience, preferably in a healthcare environment, required. Two (2) years of Medi-Cal, Medicare or Commercial Managed Care experience preferred.
About Us
About the Team
Req ID : 11981
Working Title : Managed Care Compliance Specialist - Managed Care
Department : MNS Managed Care
Business Entity : Cedars-Sinai Medical Center
Job Category : Strategic Plan / Business Dev
Job Specialty : Managed Care
Overtime Status : EXEMPT
Primary Shift : Day
Shift Duration : 8 hour
Base Pay : $34.69 - $53.77
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Diversity and Inclusion at Cedars-Sinai
We are caretakers and innovators committed to the pursuit of equitable healthcare. But health equity is not possible without representation. Our commitment to diversity goes beyond demographics or checking boxes. Our people must reflect the diverse identities, experiences and geographies of the communities and patients we serve – because that’s what our patients, colleagues and communities deserve Quality Care and Research—For All, By All.
Our compensation philosophy
We offer competitive total compensation that includes pay, benefits, and other recognition programs for our employees. The base pay range shown above takes into account the wide range of factors that are considered in making compensation decisions, including knowledge/skills; relevant experience and training; education/certifications/licensure; and other business and organizational factors. This base pay range does not include our comprehensive benefits package and any incentive payments that may be applicable to this role. Pay Transparency Non-Discrimination Provision (PDF).
Cedars-Sinai is an Equal Employment Opportunity employer.
Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law. If you need a reasonable accommodation for any part of the employment process, please contact us by email at Applicant_Accommodation@cshs.org and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this email address.
Cedars-Sinai will consider for employment qualified applicants with criminal histories, in accordance with the Los Angeles Fair Chance Initiative for Hiring.
At Cedars-Sinai, we are dedicated to the safety, health and wellbeing of our patients and employees. This includes protecting our patients from communicable diseases, such as influenza (flu). For this reason, we require that all new employees receive a flu vaccine based on the seasonal availability of flu vaccine (typically during September through April each year) as a condition of employment, and annually thereafter as a condition of continued employment, subject to medical exemption or religious accommodation. For the same reason, you may also be required to receive other vaccines as a condition of employment. Cedars-Sinai reserves the right to make modifications to its required list of vaccines as required by law and/or policy.
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