Specialty Plans Auditor III Job Category: Accounting/Finance Department: Financial Compliance Location: Los Angeles, CA, US, 90017 Position Type: Full Time Requisition ID: 11966 Salary Range: $77,265.00 (Min.) - $100,445.00 (Mid.) - $123,625.00 (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, we make sure our members get the right care at the right place at the right time. 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 and to support the safety net required to achieve that purpose. Job Summary The Specialty Plans Auditor III is responsible for planning audits and audit work programs that address appropriate claims and financial compliance criteria for specialty health plans. These audits are intended to ensure that L.A. Care delegates are in compliance with state and federal requirements and also L.A. Care contractual agreements. The position handles DMHC claims data submissions for L.A. Care and its Plan Partners and delegates etc. done each quarter and annually. The position is the liaison in external and or (CMS) claim audits Organization Determination, Appeals & Grievances (ODAG) of delegates and subsequently monitors delegates deemed deficient. Reviews department policies and procedures annually. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff. Duties Specialty Health Plan Audits. Annually performs audits of L.A. Care’s Specialty Health Plans. Plans specialty audits and develops audit work programs which address state or federal mandates regarding claims payments and solvency. Plans delegated to pay claims are audited for claims payment timeliness and related criteria, financial solvency and risk management. Prepares and submits audit reports and any corrective actions to management. Follows up with delegates to ensure corrective action plans have been implemented. Due Diligence reviews are performed as necessary during the contracting process. AB1455 Claims Monthly/Quarterly Timeliness Reports & related reports filing Collection, storage, maintenance and reporting of AB1455 Claims data by line of business submitted by Plan Partners (PP), Preferred Provider Groups (PPG), Specialty Health Plans (SHP) and Pharmacy Benefit Manager (PBM) including L.A. Care’s Claims Department. This requires interaction with pertinent staff of the aforementioned entities to resolve data discrepancies prior to DMHC filing. Responds to Department of Managed Health Care (DMHC) questions regarding data anomalies and or the department’s queries related to PPs, PPGs etc. Mandated filings are due and submitted each Quarter and Annually. Monitoring CMS Audits of L.A. Care deficient delegates. Participates in Centers for Medicare and Medicaid Services (CMS) claim audit section of L.A. Care delegates. Distributes, collects and routes the appropriate CMS Table(s) data to and from the Specialty Plan as required. Any data discrepancies, anomalies or errors require interaction with the plans to resolve. Delegates are monitored whenever CMS finds them deficient. Delegate monitoring consists of monthly or quarterly delegate data submissions for review and follow up. Duties Continued Policies and Procedures: Annually reviews and updates the department’s Policies and Procedures (P&Ps). Policies are reviewed to reflect any statutory or pertinent company policy changes. Procedures are created or updated to reflect operational changes. The updated Policy and Procedure is reviewed and approved by management prior to submission for Regulatory Affairs & Compliance and Legal review. Monitors the P&Ps routing progress and responds to questions and makes any necessary changes. Presents the P&P to the Policy Oversight Committee for final approval and implementation. Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed. Perform other duties as assigned. Education Required Bachelor's Degree in Accounting or Related Field In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Experience Required: At least 3 years of experience in conducting financial audits. At least 5 years of related experience in the managed health care industry. Minimum of 2 years of accounting experience Skills Required: Strong analytical skills and organizational abilities. Action-oriented, self-starter, and excellent motivator. Licenses/Certifications Required Certified Public Accountant (CPA) Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information 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 + Volunteer Time Off (VTO)