Job Description

The Managed Care Compliance Specialist is responsible for assisting with the implementation of the internal auditing and monitoring program within the Managed Care department by ensuring compliance with applicable rules and regulations including but not limited to AB1455 and Medicare Claims Processing Guidelines. This position is responsible for maintaining routine auditing functions and providing feedback on departmental activities, to assure compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHCS.

• Ensures all services provided to Commercial, Medicare and Medi-cal managed care members are in compliance with program regulations, insurance regulations, and regulatory requirements.
• Maintains and tracks laws and regulations, contract documentations, amendments, and various compliance measures pertaining to Commercial, Medicare and Medi-cal managed care.
• Develops policies, procedures, and processes to align with federal program regulations and any applicable state regulations pertaining to Commercial, Medicare and Medi-Cal managed care.
• Provides mentorship to various departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contract language for Commercial, Medicare and Medi-Cal managed care.
• Acts as a liaison with health plans and current CSHS departments to ensure both health plan regulations and CSHS policies are met.
• Coordinates and act as primary contact for all health plans audits, including leading all aspects of the review for performance management and accurate coding.
• Develops and supervise compliance with corrective action plans as a result of post-health plan audits and regulatory audits.
• Provides required Compliance and FWA trainings for existing, new employees and non-employees, as the need arises.
• Educates CSHS employees on company policies and procedures regarding access to care, the grievance and appeals process, the eligibility process, etc.
• Remains updated on all member and provider policy changes made by the health plan and/or the State.
• Acts as subject matter expert on health care laws/regulations as a compliance resource to CSHS and affiliates, including contracted and employed physician practices.
• Aggregates, analyze, and report audit results, identify error trends and root causes, and make recommendations for performance improvements.

Qualifications

Education:

High school diploma/GED required. Bachelor's degree in Healthcare or related field preferred.

Experience:

Five (5) years of compliance experience, preferably in a healthcare environment, required. Two (2) years of Medi-Cal, Medicare or Commercial Managed Care experience preferred.

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About Cedars-Sinai Medical Center

Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competi...tive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.

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