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Cambridge, Massachusetts
United States - Nationwide
New York, New York
Richmond, California
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Gainesville, Florida
Posted: 27-Nov-25
Location: California
Internal Number: 11981
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.
Duties and Responsibilities:- 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.