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Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (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 Financial Compliance Auditor III Finance is responsible for various tasks within the Financial Compliance Unit, including audit of the financial statements and audit of claims processed by medical groups and health plans contracted with L.A. Care. This role works closely with the Supervisor and/or Lead Auditor on identification and resolution of issues in a timely and efficient manner. This position leads assigned audits independently in accordance with general accepted auditing standards, generally accepted accounting principles (GAAP), regulations of the Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services(CMS), and other federal and state guidelines. This position is responsible for all aspects of the assigned audits including audit testing, financial solvency ratios analysis and completion of the audit report. This position includes assessment of cash, accounts receivable, risk pool receivable, current assets, accounts payable, IBNR reserves and current liabilities. This position is responsible for a variety of complex areas of the Medi-Cal, Covered California, Cal MediConnect, Healthy Kids, and PASC-SEIU benefit and process. Duties Responsible for ongoing tasks that includes but not limited to claims data reporting in the Online Monitor Tool (OMT), compiling Monthly Timeliness Report (MTR), completion of the financial statement analysis, and Plan Partner oversight of their IPA network on a quarterly &amp; annual basis. Performs auditing procedures under minimal supervision during the financial audits of medical groups and health plans. Provides timely and accurate reports that detail whether medical groups and health plans are meeting certain regulatory and contractual requirements. Communicates issues and findings that would affect the audit results. Performs audits for all medical groups and health plans contracted with L.A. Care. Timely audits reports presented to supervisor with one week of the audit date. Communicates issues and findings that would affect the audit results. Performs analysis of medical groups and plan partners. Prepares quarterly reports that analyze compliance with certain financial ratios. Sets up financial audit work papers. Performs certain administrative functions for the audit team. Sets up completely and timely work papers needed prior to going on site for the claims audits. 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. Performs other duties as assigned. Duties Continued Education Required Associate's Degree In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Experience Required: At least 5 years of experience performing financial audits with the demonstrated experience on the following list of stated knowledge/experience: Skills Required: Must be self-motivated. Detail-oriented. Able to prioritize assignments, and able to work as part of a team. Excellent verbal and written communication skills. Ability to interface professionally with both internal and external customers at all levels of the organization. Must also have flexible mode of transportation for considerable amount of travel to work off-site. Licenses/Certifications Required Licenses/Certifications Preferred Certified Public Accountant (CPA) 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 <ul> <li>Paid Time Off (PTO)</li> <li>Tuition Reimbursement</li> <li>Retirement Plans</li> <li>Medical, Dental and Vision</li> <li>Wellness Program</li> <li>Volunteer Time Off (VTO)</li></ul>

Financial Compliance Auditor III Finance

Join the transformative team at City of Hope , where we're changing lives and making a real difference in the fight against cancer, diabetes, and other life-threatening illnesses. City of Hope's growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and treatment facilities in Atlanta, Chicago, and Phoenix. our dedicated and compassionate employees are driven by a common mission: To deliver the cures of tomorrow to the people who need them today. The Hospital Compliance Auditor conducts audits systemwide to determine organizational integrity within the Hospital Compliance Program and reviews hospital and provider-based site practices and procedures to ensure they adhere to all relevant healthcare regulations and laws. Audits to evaluate systems, charge capture, and hospital billing including detection and correction of documentation, coding, and billing errors and/or medical necessity of services billed. The Hospital Compliance Auditor evaluates the adequacy and effectiveness of controls designed to ensure that processes and practices lead to appropriate execution of regulatory requirements and federal and state regulations and guidelines, CMS and other third-party payor billing rules, and OIG compliance standards. The Hospital Compliance Auditor serves as an institutional subject matter expert and authoritative resource on auditing and monitoring practices and interpretation and application of documentation and coding rules and regulations, and medical necessity of services delivered. This position sits within the Healthcare Regulatory and Reimbursement Compliance vertical of the Ethics &amp; Compliance program, is a member of the Hospital Compliance team, and reports to the System Manager, Hospital Compliance. As a successful candidate, you will: <ul> <li>Implements and manages a comprehensive systemwide proactive annual audit plan for the Hospital Compliance Program with focus on high-risk areas. </li> <li>Plans and performs hospital compliance related systems, revenue cycle, charge capture and claims audits, including accuracy and adequacy of documentation and coding related to hospital billing and/or medical necessity reviews. </li> <li>Initiates and manages auditing and monitoring as needed in conjunction with investigations and inquiries and assists with corrective action plans. </li> <li>Conducts analysis to identify inappropriate hospital billing and coding practices, identify and report compliance issues and concerns in addition to the claims and financial impact. Makes recommendations for corrective action. </li> <li>Distills and summarizes complex audit findings into digestible education and action items for stakeholders. Prepares written reports of audit findings and recommendations and presents to appropriate stakeholders; evaluates the adequacy of management corrective action to improve deficiencies; maintains audit records. </li> <li>Assists in validating accuracy of external audits, utilization management reporting, and other inquiries. </li> <li>Assists departmental management with the development of tools, templates, and process improvement recommendations. </li> <li>Assists in documentation and internal evaluation of Ethics &amp; Compliance Program effectiveness consistent with professional standards. </li> <li>Understands where regulatory guidance and hospital policies and procedures might intersect in terms of compliant billing and coding, provide customer feedback to guide their decision making. </li> <li>In conjunction with department manager, provides education and feedback to stakeholders when audit deficiencies are identified. </li> <li>Stays current with Medicare, Medicaid and other third party rules and regulations, CPT, ICD10 coding updates and enhances professional growth and development by participating in educational programs relating to such topics. Serves as a system resource to answer billing appropriateness questions and those arising from audits, including government audits. </li> <li>Maintains knowledge of City of Hope Provider billing and collection systems, including knowledge of report writing capability, and works with Information Systems personnel to identify and request data needed for audits. </li> </ul> Your qualifications should include: <ul> <li> Bachelor's degree; 3 additional years of experience plus the minimum experience requirement may substitute for minimum education. </li> <li> Seven (7) years auditing and coding experience. </li> </ul>City of Hope employees pay is based on the following criteria: work experience, qualifications, and work location. City of Hope is an equal opportunity employer. To learn more about our Comprehensive Benefits, please CLICK HERE .

Hospital Compliance Auditor

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (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 Delegation Oversight Compliance Auditor III is responsible for planning, coordination, and conducting comprehensive compliance audits and reviews to assess adherence to regulatory requirements, contractual obligations, and internal policies for L.A. Care subcontracted providers. Additionally, the Auditor III will provide updates and recommendations to Management on quality and delegation oversight responsibilities, participate in fraud, waste, and abuse investigations as applicable, and oversee pre-delegation and annual audits for new and existing delegated entities to drive continuous improvement and adherence to regulatory standards by ensuring delegates are compliant with regulatory requirements. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff. Duties 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. Regulatory: Researches, analyzes, and interprets contractual, state, and federal regulatory, and accreditation requirements. Stays abreast of changes in healthcare regulations, laws, and industry standards; analyzes regulatory developments and assesses their impact on the organization. Updates existing audit tools and creates audit tools based on the regulatory requirements. Assists management team with informing team of regulatory changes to ensure alignment with regulatory requirements and industry best practices. Audit: Plans, coordinates, and conduct with other auditors and conducts comprehensive compliance audits and reviews to assess adherence to regulatory requirements, contractual obligations, and internal policies for L.A. Care subcontracted providers including, but not limited to, Participating Physician Groups, Plan Partners, and Specialty Health Plans/Vendors. Independently conducts complex audits, including scoping, research, tool development, field work, reporting, and corrective action plan validation. Identifies, documents, and trends audit issues and provides appropriate coaching and shares best practices with delegated entities to assist with performance improvement. Investigate and Risk Assessment: Investigates and escalates allegations of non-compliance, fraud, or misconduct; develops and implements corrective action plans to address identified issues and prevent recurrence. Conducts risk assessments to identify compliance risks and develops strategies to mitigate risks and strengthens internal controls. Alerts management of identified new or emerging compliance risks and makes recommendations on DOA's audit plan or monitoring plan to other business unit. Serves as a subject matter expert in compliance auditing, risk assessment, risk mitigation planning and regulatory interpretation and application. Duties Continued Collaboration: Leads entrance calls, exit conferences, and technical calls with delegates. Collaborates with cross-functional teams, including but not limited to Legal, Compliance, Quality Assurance to address compliance-related challenges and delegate's performance deficiencies, and implement effective solutions. Assists management to establish processes to track program effectiveness; monitor and analyze data to identify trends and areas for improvement. Works closely with Delegation Oversight Audit management on and to co-lead projects. Reports: Prepares and presents comprehensive reports and presentations to senior leadership, internal Committees, external entities, summarizing compliance activities, findings, and recommendations. Reviews and provides feedback on work papers of other Auditors to ensure accurate testing, results, and reports, and to ensure adherence to departmental procedures and protocols. Training: Develops and delivers compliance training programs for internal staff members, such as Delegation Oversight Audit team, and other business units within L.A. Care. In addition, to develop training programs for delegates as external entities ensuring awareness of compliance requirements and promoting a culture of compliance throughout the organization and with delegates. Leads and manages compliance projects and initiatives, auditors' trainings. Develops training materials, updates audit tools, performs risk assessments, policy development, and process improvement efforts. Perform other duties as assigned. Education Required Bachelor's Degree in Healthcare Administration or Related Field In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Experience Required: At least 4 years of audit experience in compliance, delegation oversight, or audit within the healthcare industry. Demonstrated experience developing and delivering training programs and making presentations to internal staff and providers. Experience in health care service plans with significant delegation arrangements. Experience working with Policies and Procedures. Skills Required: Ability to manage multiple priorities, projects and meet deadlines. Superior written and verbal communication skills. Ability to draft policies and procedures. Exceptional analytical and problem-solving skills, with a meticulous attention to detail. Strong communication and collaboration abilities, with the capacity to engage effectively with stakeholders at all levels. Ability to create a work environment that fosters team building and encourages a collaborative approach to achieving departmental and organizational goals. Proficient in Microsoft Office, Excel, and PowerPoint. In-depth knowledge of federal and state laws, Medicaid regulations, and healthcare compliance standards. Licenses/Certifications Required Licenses/Certifications Preferred Certified HealthCare Compliance (CHC) 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 <ul> <li>Paid Time Off (PTO)</li> <li>Tuition Reimbursement</li> <li>Retirement Plans</li> <li>Medical, Dental and Vision</li> <li>Wellness Program</li> <li>Volunteer Time Off (VTO)</li></ul>

Delegation Oversight Compliance Auditor III

Job Description The Compliance Auditor, Billing and Coding Compliance is responsible for the oversight and management of auditing and monitoring billing and coding compliance activities, developing policies and procedures, completing compliance risk assessments, and developing risk-based educational materials to ensure compliance with federal/state laws and regulations, and UT Health San Antonio policies. Responsible for effectively communicating information and audit findings through presentations, graphs, reports, and educational materials, etc. Responsibilities <ul> <li>Provide oversight on billing compliance auditing, monitoring, and educational activities within the compliance department</li> <li>Performs audits of electronic and manual documentation, coding, and billing systems.</li> <li>Conducts close-out meetings with senior management of audited departments.</li> <li>Maintain current knowledge of changes in federal and state coding and billing regulations/guidelines and ensure staff is kept informed.</li> <li>Create adit schedules and manage workflows to adhere to the audit schedule.</li> <li>Develop methods to effectively communicate information through presentations, graphs, reports, educational materials, etc.</li> <li>Develop, establish, and review policies and objectives consistent with those of the organization to ensure efficient departmental operations.</li> <li>Performs charge audits by comparing itemized bill to medical record documentation to ensure appropriate charging</li> <li>Review, assess, study, and analyze the overall coding, billing, documentation, and reimbursement system for potential compliance problems.</li> <li>Serve as a point of contact for reports of billing compliance concerns or potential issues. Respond timely and professionally.</li> <li>Monitor emerging changes and trends in the law, regulations and industry standards relating to compliance with and enforcement of applicable law and report impactful developments. Performs research, as needed.</li> <li>Collaborate broadly across business and operational areas within the university to analyze and assess business processes, data, and risk controls.</li> <li>Performs medical record audits of documentation, coding and billing for technical and professional services, 340-B Pharmacy, grant-funded research, risk adjustment, non-physician practitioner documentation (including "incident-to guidelines, teaching physician guidelines, dental, and other areas as identified. maintains communication with auditors and other relevant individuals/organizations until all identified discrepancies are resolved.</li> <li>Analyze data/reports to identify and address trends, issues, and risk areas</li> <li>Participates in the development of voluntary disclosures and repayments to federal and state agencies.</li> <li>Performs all other duties as assigned.</li></ul>Qualifications <ul> <li>Ability to review, analyze, and interpret regulatory requirements in a clear and concise manner.</li> <li>Demonstrates in-depth knowledge regarding professional/hospital coding, billing and revenue cycle, research grant funding, as well as Health Information Management (HIM) operations. Has a working knowledge of electronic auditing tools like MDAudit.</li> <li>Highly organized with ability to independently analyze, conduct research and present findings/relay information to other departments/teams on various compliance, documentation, coding and finance-related topics.</li> <li>Knowledge of treatment protocols, medical and surgical procedures and other healthcare practices.</li> <li>Knowledge of state and federal laws applicable to healthcare and compliance industry.</li> <li>Current Procedural Terminology (CPT) and Diagnosis Related Group (DRG) coding knowledge.</li> <li>Ability to self-direct and prioritize work.</li> <li>Detail oriented with excellent organizational skills and high degree of integrity and confidentiality.</li> <li>Advanced computer database and Microsoft Office software skills.</li> <li>Excellent customer service skills and strong willingness to take initiative.</li> <li>Strong verbal, written and interpersonal communication skills.</li> <li>Ability to present to small or large groups.</li> <li>Ability to commute to various UTHSA facility locations within a 50-mile radius of the University Campus.</li> <li>Established track record working with EPIC EHR system.</li></ul>EDUCATION: <ul> <li>Bachelor's degree required.</li> <li>Experience in lieu of a degree</li> <li>Graduate level degree or will have acquired professional experience working with an auditing/consulting company preferred</li></ul>EXPERIENCE: <ul> <li>Three (3) to five (5) years of experience working in a professional fee clinic and teaching hospital (inpatient and outpatient) settings.</li></ul>LICENSE AND CERTIFICATION: <ul> <li>None</li></ul>About Us Benefits Overview UT Health San Antonio offers an excellent benefits package for its employees. Employees who work at least 20 hours a week, with an appointment of at least 4.5 months, are eligible for benefits. Medical - UT SELECT Medical insurance is offered free for employees and administered by Blue Cross and Blue Shield of Texas. Family members can be added to the plan through payroll deduction. Employees and their dependents can also receive discounted copays and coinsurance when using UT Health Physicians, a network of 800 premier physicians including more than 100 specialists. Dental - Three dental insurance plan options are available for employees and their families through Delta Dental Insurance Company, two PPOs and one dental HMO plan. Both PPO plans allow employees to choose any licensed dentist. Vision - Fully insured Vision Care benefits are offered by Superior Vision Services. Two vision plan options that offer either standard or enhanced vision benefits. Life Employees receive $40,000 of group term life insurance and $40,000 of basic accidental death and dismemberment insurance for free, with options to purchase additional employee and dependent coverage for both at group rates. Retirement - Employees are eligible for either the Teacher Retirement System (TRS) or the Optional Retirement Plan (ORP). TRS is a defined benefit retirement plan which UT Health matches employee contributions. ORP is for eligible faculty staff employees. Voluntary retirement programs are also available to invest before- or after-tax dollars with the choice of five quality retirement plan providers. Time Off - A generous leave program offers multiple paid leave options: <ul> <li>Front-loaded Paid Time Off: 128 to 208 hours (16 to 26 days) of Paid Time Off based on years of service, given at the start of each fiscal year. PTO may be prorated in year one based on date of hire.</li> <li>Extended Illness Bank: 8 hours (1 day) accrued per month which can be used for illness or injury after one day of Paid Time Off is taken.</li> <li>Paid Family Leave: Up to 240 hours (6 weeks) to care for a spouse, child, or parent after 6 months of consecutive employment.</li> <li>Holidays: 12 set paid holidays each year.</li> </ul>FSAs - Employees can enroll in flexible spending accounts (FSAs) to set aside money from earnings before taxes for qualifying dependent day care expenses or out-of-pocket health care expenses. Discounts - Employees enjoy a range of discounts on services, tickets, and gym membership. EEO Statement UT Health San Antonio is an equal employment opportunity and affirmative action employer. It is our policy to promote and ensure equal employment opportunity for all individuals without regard to race, color, religion, sex, gender identity, national origin, age, sexual orientation, disability, or veteran status.

Compliance Auditor, Billing and Coding

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (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 Financial Compliance Auditor III Claims is responsible for various tasks within the Financial Compliance Unit, including audit of claims processed by medical groups and health plans contracted with L.A. Care. This role works closely with the Supervisor and/or Lead Auditor on identification and resolution of issues in a timely and efficient manner. For Claims Emphasis: This position is responsible for all aspects of assigned claim audits, including audit testing and completion of the audit report. This position is responsible for a variety of complex areas of the Medi-Cal, Medicare, Covered California, and PASC-SEIU benefit and process. This position audits focuses on contractual and regulatory compliance with timeliness and appropriateness standards. This position is responsible for other ongoing tasks as assigned by the Manager of Financial Compliance. These assignments may include claims data reporting in the Online Monitor Tool (OMT), compiling Monthly Timeliness Report (MTR), completion of the financial statement analysis, and Plan Partner oversight of their Independent Practice Association (IPA) network on a quarterly &amp; annual basis. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff. Duties Perform auditing procedures under minimal supervision during the audits of medical groups and health plans. Provide timely and accurate reports that detail whether medical groups and health plans are meeting certain regulatory and contractual requirements. Communicate issues and findings that would affect the audit results. Perform claims audits for all medical groups and health plans contracted with L.A. Care. Timely audit reports presented to supervisor with one week of the audit date. Communicate issues and findings that would affect the audit results. Perform analysis of medical groups and plan partners. Set up financial audit work papers. Perform certain administrative functions for the audit team. Set up completely and timely work papers needed prior to going on site for the claims audits. Perform other duties as assigned. Duties Continued Education Required Bachelor's Degree In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Master's Degree Experience Required: A minimum of 5 years of experience performing claims audits or claims processing related to Medi-Cal, Cal MediConnect, and/or other managed care product lines similar to L.A. Care's, L.A. Care Covered, and PASC-SEIU programs. Skills Required: Must be self-motivated. Detail-oriented. Able to prioritize assignments, and able to work as part of a team. Excellent verbal and written communication skills. Ability to interface professionally with both internal and external customers at all levels of the organization. Must also have flexible mode of transportation for considerable amount of travel to work off-site. Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices. Knowledge of medical records systems applications. Knowledge of the insurance industry's trends, directions, major issues, regulatory considerations and trendsetters. Knowledge of health insurance products, market segments and marketplaces. Licenses/Certifications Required Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Delegates: This position also conducts sub-delegation claims oversight audit of the PPGs, capitated hospitals and the Plan Partners. This includes all claims processing sub-contracting functions of the delegates. 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 <ul> <li>Paid Time Off (PTO)</li> <li>Tuition Reimbursement</li> <li>Retirement Plans</li> <li>Medical, Dental and Vision</li> <li>Wellness Program</li> <li>Volunteer Time Off (VTO)</li></ul>

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