Compliance Auditor is responsible for planning and conducting internal and external audits of Yamhill Community Care (YCCO) and its subcontractors, partners, and medical claims, as well as monitoring trends of non-compliance against established criteria such as policies and procedures, Oregon Administrative Rules, and federal laws and regulations.
Essential Duties Follows state and federal regulations as well as internal policies and guidelines. Implements, oversees, and performs internal audits for YCCO. Conducts routine compliance audit reviews including claims audits, subcontractor audits, and ad hoc audits. Performs contractually required audits of YCCO subcontractors. Job Duties
Analyzes audit results to determine the root cause of errors and recommends process improvements. Reviews error trends to identify training opportunities. May provide education on regulatory compliance and follow up with corrective action activities under the guidance of the Compliance Officer.
Assists with development of annual audit plan, including risk backssment development and compilation of results, and presentation of the annual plan to appropriate committees and leadership for approval. Creates and maintains audit records, analytical reports, and track and trend audit program activities. Helps evaluate the adequacy and effectiveness of internal and operational controls designed
to ensure that processes and practices lead to the appropriate execution of regulatory requirements and guidelines related to the organization’s integrity and compliance.
Monitors regulatory, legal, and industry developments and identifies opportunities for their application to the Compliance program. Manages compliance program incident logs. Maintains accurate, complete, and up-to-date compliance documents and records and produces for the Compliance Officer upon request. Other duties as assigned. Essential Department & Organizational Functions Responsible for evaluating YCCO’s compliance to key operational, legal, and regulatory language within the Oregon Health Authority (OHA) contract, Oregon Administrative Rule, and Code of Federal Regulation.
Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members. Participates in the preparation and submission of regulatory and contract required deliverables. Works closely with other YCCO departments, including Health Plan Operations and Compliance to assist with audits; including the External Quality Review (EQR), as needed. Performs internal audit investigations and assists with fraud, waste, and abuse investigations throughout the health plan and compiles detailed reports with recommendations to the Compliance Officer.
Assists with the development of annual audit plans according to the annual YCCO risk backssment. Proposes and implements process improvements. Meets deadlines for completion of assigned responsibilities and projects. Maintains agreed upon work schedule with punctual, regular, and predictable attendance. Demonstrates cooperation and teamwork using a professional and respectful demeanor. Provides cross-training on specific job responsibilities. Meets identified goals that contribute to departmental goals.
Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation. Respectfully takes direction from Supervisor. Other duties as assigned. Knowledge, Skills, & Abilities Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy. Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix or shared resources across departments work model.
Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook. Excellent computer skills are needed with a strong proficiency in Excel and similar tools and the ability to effectively manipulate and organize complex data. Curious, detail-oriented, and inquisitive mindset. Organizational and time management skills, along with an ability to skillfully handle time-sensitive projects. Analytical, problem-solving, and decision-making skills to work through challenging and complex details. High degree of integrity and confidentiality required for handling information that is personal and confidential.
Strong written and verbal communication skills, including the ability to obtain information from others and deliver information in a concise, clear, and accurate manner. Ability to work independently, when needed, and to use sound judgment, anticipate next steps and be proactive. Ability to communicate both professionally and effectively in all forms of communication. Ability to work in an environment with diverse individuals and groups. Ability to remain flexible, positive, and adaptable. Ability to work across the YCCO region and to work remotely, as needed.
Supervisory Responsibilities This position has no supervisory responsibility. Qualifications Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties. Education & Experience Required: At least two (2) years of healthcare auditing experience.
OR: Any combination of education and experience that would qualify candidate for the position. Preferred: Five (5) years of healthcare auditing experience. At least two (2) years of Healthcare Auditing experience in the Medicaid / Medicare realm. Bachelor’s degree in Healthcare or related field. Experience and knowledge in Health Plan Compliance and Auditing. Certificates, Licenses and/or Registrations Certified Professional Coder (CPC) or equivalent certification required. Physical Demands & Work Environment The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position.
The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms.
The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds. This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate. This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.
