The Managed Care Compliance Specialist is primarily responsible for assisting the Compliance Manager in the coordination and facilitation of all regulatory audits impacting managed care operations (MCO). This position is responsible for helping develop the compliance function within MCO to ensure all applicable rules and regulations are followed. This includes but is not limited to, maintaining MCO policies and procedures (compliance and operations), coordinating and producing all documentation during health plan audits, and Corrective Action Plan (CAP) tracking and trending.
Essential Job Duties and Responsibilities:
Provider support to the compliance team and additional stakeholders regarding compliance related matters.
Provides support to develop and enhance the compliance function for managed care operations.
Serves as a point of contact between Claims department and health plans in the coordination of all health plan and state/federal audits.
Gathers, organizes, and tracks all documentation submitted during audits.
Submits, validates, and tracks all monthly timeliness reports
Assists with the completion of corrective action plans, and provides assistance to ensure successful implementation of corrective action plans
Assist the manager to conduct periodic internal reviews to ensure that compliance procedures are followed
Identify compliance issues that require follow-up or investigation.
Participates in meetings, training and conference calls as requested
Participates in workshops, seminars, audio conferences and other educational opportunities to ensure continued learning for self-improvement
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 competitive 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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