Compliance specialist

Employment Type

: Full-Time


: Miscellaneous

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Under the direction of Compliance Counsel, and in support of the Compliance and Legal Division, this position: performs audits of functional areas; coordinates health plan delegation audits of BTP functions; conducts investigations into non-compliance, privacy, and potential incidents of fraud, waste, and abuse (FWA); and assists Compliance Counsel in Compliance training and education efforts.Essential Job Functions:Assists in the implementation of audit processes to ensure compliance with federal and state laws and regulations, program guidelines, and contractual obligations, with duties including but not limited to:Supporting the audit program and implementing ongoing risk assessment activities;Conducting audits, analyzing information, identifying deficiencies, developing reports, and formulating recommendations for corrective action;Informing Compliance Counsel and Chief Legal Officer regarding situations of non-compliance;Working with department directors and managers to implement corrective action plans in situations of non-compliance, monitoring progress and ensuring completeness; andMonitoring compliance risks and ensuring that BTP responds appropriately.Responds to external audit notices, with duties including but not limited to:Replying to audit requests from health plan partners, and acting as the main point of contact for health plan audits;Coordinating responses from appropriate department directors and managers; andAssisting in the preparation of Corrective Action Plans.Participates in the day-to-day operations of the FWA and Privacy Programs to meet department and organization objectives, with duties including but not limited to:Responding to inquiries and incidents reported to Legal & Compliance by BTP employees, health plan partners, physicians, patients/members, and other interested parties;Investigating incidents with efficiency and effectiveness, and ensuring the quality and accuracy of work product, including research, evidence gathering, interviewing, reviewing documents, drafting reports, and determining whether a substantiated incident requires regulatory reporting;Collaborating with internal partners on FWA, Privacy, and Compliance initiatives;Analyzing data and creating reports for various committees and bodies of the Board of Directors;Reviewing relevant policies and procedures, and making recommendations for revisions, as identified; andMaintaining current knowledge of relevant State and Federal FWA and Privacy laws and regulations;Assists Compliance Counsel in training and educational efforts around Compliance, Privacy, and FWA, with duties including but not limited to:Aiding Human Capital in providing required training to new employees;Reviewing and revising Compliance, FWA, and Privacy training materials on a regular basis; andLeading efforts to create educational events for the entire BTP workforce to reiterate the organization’s commitment to compliance.Education and/or Training:Working knowledge of State and Federal privacy and FWA laws and regulations, as well as knowledge of guidance set forth by the Centers for Medicare & Medicaid Services (CMS), California Department of Managed Health Care (DMHC), California Department of Health Care Services (DHCS), and California Department of Insurance (CDI).Basic knowledge of managed health care systems preferred.High school diploma or equivalent required. Bachelor’s degree highly preferred.Skills and Abilities:Ability to investigate and research complex issues involving health plans, patients/members, physicians, and other healthcare providers.Strong verbal and written communication skills.Knowledge of contemporary office practices and procedures.Experience:Three years of auditing or investigative experience in a healthcare organization. Experience in a managed care environment preferred.

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