Network Compliance Auditor, FSR – RN

This is a fully remote position, open to applicants in California.

📋 Description

• Oversee and manage the auditing team for the Managed Care Plan’s DHCS.

• Conduct and supervise both initial and follow-up assessments of Primary Care Provider locations, including Facility Site Reviews and Medical Record Reviews.

• Complete monthly audit tasks within set deadlines while ensuring thorough and compliant documentation.

• Analyze, interpret, and review DHCS All Plan Letters, alongside legislative, statutory, regulatory, and contract language.

• Create implementation and communication strategies for regulatory compliance and provider data requirements.

• Audit SCAN-contracted and collaborative PCP offices catering to Medi-Medi members in accordance with CMS, DHCS, and contractual obligations.

• Offer training, feedback, and suggestions for improvement regarding auditing and post-audit documentation.

• Facilitate closing meetings and provide initial summaries of compliance audit findings.

• Assist providers with corrective action plans, monitor CAPs, and offer education and compliance resources.

• Address provider disputes concerning audit results and evaluate submitted reports and correction requests.

• Clarify regulatory interpretations and their application.

• Lead annual oversight initiatives, correspondence, project management, delegated compliance monitoring, status updates, and regulatory update coordination.

• Act as a subject matter expert in service delivery compliance for the Delegation Oversight Unit.

• Collaborate with Compliance on SCAN policies pertaining to NCQA, DHCS, CMS, and other regulatory updates.

• Report long-standing non-compliance issues and identify obstacles for supervisors/managers.

• Educate providers on delegated claims processing and issues related to member liability denials.

• Review compliance program processes, delegated administrator letters, and data submissions for accuracy and adherence.

• Ensure member privacy and maintain confidentiality of information.

• Comply with quality, regulatory, and compliance standards.

• Support SCAN’s vision and objectives while performing additional duties as assigned.

⛳️ Requirements

• Active Registered Nurse License (RN) required (current California license in good standing).

• Minimum of 2 years of clinical experience, including but not limited to ER/Acute Care nursing.

• Associate's Degree in Nursing.

• DHCS-CSR (certified site reviewer) designation preferred.

• Prior experience in auditing preferred.

• Capability to work both independently and collaboratively in a team setting.

• Basic to working knowledge of relevant subject matter.

• Fundamental technical skills related to the functional area.

• Basic problem-solving abilities.

• Strong communication and interpersonal skills.

• Proficient analytical, critical thinking, problem-solving, and decision-making skills.

• High attention to detail and excellent organizational abilities.

• Capacity to manage multiple competing tasks in a dynamic environment.

• Proficient in MS Office and data entry.

• Valid driver’s license, automobile insurance, and reliable transportation.

• Ability to travel within assigned territory and adapt to other areas as required.

• Background check mandatory.

🏝️ Benefits

• Annual employee bonus program.

• Comprehensive Wellness Program.

• Generous paid time off (PTO).

• 11 paid holidays each year.

• 1 floating holiday.

• Birthday off.

• 2 volunteer days.

• Excellent 401(k) Retirement Savings Plan with employer matching.

• Robust employee recognition program.

• Tuition reimbursement.

• Equal pay and inclusive benefits.

• Opportunity to join a team that positively impacts members and the community.