Job Details

The Managed Care Compliance and Audit Coordinator (C & A Coordinator) works closely with the Managed Care Compliance and Audit Manager to assist with compliance and auditing functions of NEMS MSO (Management Services Organization), including, but not limited to, internal and external audit activities of claims processing and adjudication, Utilization Management, Credentialing, Case Management, and quality improvement initiatives. This role will also be responsible for monitoring regulatory requirements, understanding how requirements impact MSO operations, and assist with providing guidance to relevant teams.

ESSENTIAL JOB FUNCTIONS:

• Conduct internal audits to systematically assess the department's risks and efficacy of delegated functions and activities, policies, and procedures, using assessment and auditing tools approved by contracted health plan and/or developed internally.
• Coordinate inter-department and cross-department level projects including planning, workgroup meetings, collecting and setting agenda items, creating meeting minutes, and following up with action items.
• Assist with administrative tasks from the MSO Compliance and Audits (C&A) Manager. The C&A Team and other MSO units work collaboratively to promote quality assurance and quality improvement activities.
• Collaborate with different MSO units and external provider offices to aid plans in the investigation of member grievances and potential quality issues (PQI). Assist with the issuance of CAPs for identified non-compliance and monitors for remediation.
• Collaborate with different MSO units, including Claims, UM, Provider Relations, Care Management, and Data Reporting, to relay compliance requirements, audit scores, corrective action plans, and to ensure non-compliance area(s) is corrected and monitored.
• Work closely with MSO C&A manager, department managers, and external health plan auditors with compliance audit activities, including but not limited to internal and external of communication about audit calendar/schedule and level of requirement, report submission, gathering of documents, etc., to facilitate a smooth and positive audit experience from external auditors.
• Analyze regulatory guidance documents, document requirements, understand & communicate requirements, and collaborate with different teams to monitor compliance.
• Analyze reports and present findings to the C&A team and different MSO units.
• Collaborate with different teams and departments to ensure compliance with NCQA standards to maintain NEMS's NCQA accreditations.
• Performs other job duties as required by manager/supervisor.

QUALIFICATIONS:

• Bachelor's degree in relevant field is required. Combination of education and relevant work experience may be considered in lieu of a Bachelor's degree.
• Experience in a healthcare setting or managed care is strongly preferred.
• Experience in compliance and/or operational auditing is preferred.
• Previous experience in quality assurance and quality improvement related activities in healthcare related setting is preferred.
• Experience with analyzing and presenting data is preferred.
• Knowledge of NCQA standards and guidelines is preferred.
• Strong knowledge of Microsoft Office (PowerPoint, Word, Excel, Outlook)
• Excellent written and verbal communication skills.
• Ability to multi-task and work with highly sensitive and confidential matters.
• Excellent problem-solving skills and be able to think critically.
• Excellent interpersonal and customer service skills.
• Ability to work with all levels of staff.

LANGUAGE:

• Must be able to fluently speak, read, and write English.
• Fluent in Chinese (Cantonese and/or Mandarin) preferred
• Fluency in other languages are an asset.

STATUS:

• This is an FLSA Non-exempt position.
• This is not an OSHA high-risk position.
• This is a Full Time position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).