Healthcare / Medicare Audit

POSITION DESCRIPTION, DUTIES & RESPONSIBILITIES: • Establish detailed audit programs to monitor and assess operations, policies and procedures within all major functional areas including: medical management, network management, contracting, sales and marketing, customer service, compliance, enrollment and eligibility, and claims processing • Perform oversight and monitoring of outside contractors and delegated entities to report on compliance with company and regulatory policies and procedures • Prepare audit reports with details of findings and proposed corrective actions, when necessary • Utilize appropriate statistical methods and generally accepted auditing procedures when appropriate (determination of appropriate sample size, random selection, establishment of materiality levels) • Work with quality & compliance departments to develop baseline data in order to identify outliers and trends • Report to operations committees and compliance officers as required • Stay abreast of developments in auditing standards as well as applicable federal and state guidelines, policies and procedures EDUCATION/EXPERIENCE REQUIRED: • Four year degree in finance or accounting • At least two years of experience as an internal auditor or equivalent in the operations of a health insurance company or in a related health care industry. • Medicare Advantage/Prescription Drug program expertise desired, including understanding of compliance requirements, monitoring guidelines, and regulatory standards • MUST enjoy and be able to multi-task in a very fast-paced organization with little direct oversight • Knowledge of standard health plan organizational structures, workflows and operating procedures • Ability to communicate effectively, both orally and in writing • Ability to analyze complex non-financial data and develop meaningful reports for internal and external use • At least two years experience in the development of effective audit programs and the use of standard auditing techniques • Occasional regional travel may be required RemX Financial Staffing is an Equal Opportunity Employer